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STATE OF CALIFORNIAN.- WATER RESOURCESCONTRO.,dOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM ' '? TANK TANK PERMIT APPLICATION INFORMATION ,zm COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 RMANENTLY CLOSED TANK ONE ITEM F-12 INTERIM PERMIT El AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED ©q FACILITY/SITE NAME WHERE TANK IS INSTALLED: - FARM TANK-YES❑ NO—w Ln I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY W A. OWNERS TANK IDR V B. MANUFACTURED BY V14[_, 1--i C. YEAR INSTALLED �j D. TANK CAPACITY IN GALLONS: QQ Q 11. TANK NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,C-qMPLETE ITEM D. A 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC.B I UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT [:] 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.R CAS If III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOA A,B,C,&D A TYPE OF ❑ I DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM T/sINGLE WAILED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC R.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 IDA METHANOL COMPATIBLE FRP MATERIAL Q ❑9 BRONZE ❑ ID GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ C. INTERIOR 1 RUBBER LINED ❑ LKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC UNI LINING ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION /POLYETHLENE WRAP F-1 F-12 TAR OR ASPHALT 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION S CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMA ION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A i 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A LA I 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 A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION YSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. S1 VISUAL CHECK 5 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 5 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL'± E]YES [:] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY A FACILITY ID R TANK ID k CURRENT LOCAL AGENCY F CILITY ID I/J/� APPROVED BY NAME PHONE N WITH AREA CODE 6 i PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT ")RCHARGE AMT. FEE CODE -EIPT N BY: (\ I Z9 � FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' NAS BEEN FILED