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STATE OF CALIFORN% WATER RESOURCES CONTR ARD , FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. I MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLYCNK ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED N ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT JE9 ,r>�N FARM TANK-YES❑ NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: y'- I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY N B. MANUFACTURED BY: A. OWNERS TANK IDp I� 6 O D. TANK CAPACIN IN GALLONS: � (7 P C.YEAR INSTALLED 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMFP�LDE DE ITEM 2 LEADED ❑ 3 DIESEL D. A. v❑ 1 MOTOR EMICALVEHICLE FUEL ❑ 2 PETROLEUM B. ❑4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑3 HAZARDOUS ALPRODUCT ❑ 4 OIL ❑ 1 PRODUCT 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) ❑5 HAZARDOUS ❑ 60 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ ❑ D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,d D A. TYPE OF7F',-�'2 ❑ I QOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM INGLEWAUEO ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEELIIRON ❑2 STAINLESS STEEL ❑ 3FIBERGLASS ❑ 4STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP MATERIAL ❑y BRONZE ❑10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RU38ERLINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4P)OOUWN LINING LINING C. INTERIOR ❑ ❑ LINING 5 GLASS UNING 6 UNLINED � ISLINING MATERIAL COMPATIBLE WITH 10096 METHANOL? ❑YES ❑ NO 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 INYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION F-15 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE AIF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLENONE A 95 UNKNOWN A_U 99 OTHER A. SYSTEM TYPE A U 1 SUCTION A U PRESSURE B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U 91 NONE 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 5 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. p S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS PL-8 14 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S I PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE /P/S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH 2. ESTIMATED QUANTITY OF INERT MATERIAL? 0 YES E] P 1. ESTIMATED DATE LAST USED(MO/VRI SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY COUNTY# JURISDICTION � AGE FACILITY ID# TANK ID# m FTIZ= cJ [� APPROVED BY NAME PHONE#WITH AREA CODE CURRENT LOCAL AGENCY FACILITY ID# PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT NUMBER CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT# BY: FORM B(s-29-eBl THIS FORM MUST BE ACCOMPANIED BYAFACILITY/SITE APPLICATION, FORM 'A',UNLESS AcURRENT FORMA' HASBEENFILED