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N STATE OF CALIFORK.4 WATER.RESOURCES CONT BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION �� v COMPLETE A SEPARATE FORM WITH THE FOLWWIN INFORMATION FOR EACH TANK. r MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK 15 INSTALLED: FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# # f B. MANUFACTURED BY; m o de s tp we-fall,n C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: J 000 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.1F(A.1),IS NOT MARKED,COMPLETE ITEM D. CAI A. ❑ 1/MOTOR VEHICLE FUEL F-] 2 PETROLEUM 8.' C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL � ©'3 CHEMICAL PRODUCT ❑ 4 OIL ❑ T PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL 9?19"9 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE OF HAZARDOUS SUBSTANCE STORED&C.A.S.# S `D GI�CQ ar'c so L U e n f C.A.S.L S o 5 A W3 . xlll. TANKCONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&0 A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM (.'11SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER k B.TANK 5 CONCRETE� ONCRETEE R ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 SM CLAD WIRBERGLASS REINFORCED PLASTIC f ❑ MATERIAL ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM' ❑6 100%METHANOL COMPATIBLE FRP 1 ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD UNING El3 EPDXY UNING ❑4 PHENOLIC LINING - LINING ❑ 5 GLASS LINING �UNUNED ❑95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YfS ❑ NO ❑99 OTHER -0. CORROSION ❑.1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3VINYL WRAP ❑4 RBERGLASSREINFORCED PLASTIC PROTECTION ❑ 5 CATHODICPROTECTION ERV NDNE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A Fa>1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U "OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 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 _ C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCIAOW/FRP A U -8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 95 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 5 1 VISUAL CHECK f�A 5 2 INVENTORY RECONCILIATION p 3 3 VADOSE WELLS P 5 4 ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS f P S 6?RECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE' P S 95 UNKNOWN P S 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 N IS. SUBGALLONS STANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO I-7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 39I ' t El : a ..Q / I33 rol 00 / CURRENT LOCAL AGENCY FACILITY ID N APPROVED SYN E PHONE#W"AREA CODE ke PERMIT NUMBER PERMIT APPROVAL D PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: r FORM B(3-7-881 THIS FORM MUST BE ACCOMPANM6'BY A FACILITY/SITE APPLICATION, FORM`A',UNLESb A CURRENT FORMA' HAS BEEN FILED _DATA PROCESSING COPY