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STATE OF CALIFORNI - WATER RESOURCES CONTR( 30ARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION [_] 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDEDPERMIT [:] 6 TEMPORARY TANK CLOSURE E]8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: S FARM TANK-YES❑ NO z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY IG A. OWNERS TANK ID# B. MANUFACTURED BY: K C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS. w I1. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF/(A.1),IS NOT MARKED,COMPLETE ITEM D. Vl MOTOR CLE 7TNZED LEADED 3 DIESEL A ❑3 CHEMICAL PIR DUCTL ❑4 CPETROLEUM l PRODUCT C ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ ❑ 5 HAZARDOUS ❑ 80 EMPTY 0 95 UNKNOWN LLL2 WASTE ❑ 7 METHANOL Ej 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: .111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,A D A.TYPE OF ❑ I DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM [2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER I STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑M OTHER C. INTERIOR ❑ I RIBBER LINED E] 2 ALKYD LINING ❑3 EPDXY LINING ❑ /P ENOUC UNINO LINING F-15 GLASS LINING ❑6 UNUNED5 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YEST�L❑ NO ❑99 OTHER D. CORROSION F-11 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:] 5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A I LA I SUCTION A U 2 PRESSURE A U 3 GRAVITY A99 OTHER B. CONSTRUCTION A U / SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 95 UNKNOWN A U MOTHER A U I STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUMA 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8I0 METHANOLCOMPATIBLEFRP A U 9 GALVANIZED STEEL U 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. 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P 3 4 ELECTRONIC MONITOR P S S GROUNDWATER MONITORING WELLS P 6 PRECISION TESTING B ] PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES 0 NO 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 A SIGNATURE) DATE ! LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# FU = OU 6 1 600 12- CURRENT CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME ' / _PLLONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATES SLAY` CHECK# PERMR AMOUNT -. SURCHARGE AMT. FEE CODE I RECEIPT# BY: FORMB(3-7-8B) THIS FORM MUST BEACCOMPA DBYAFACIL(IY/SITEAPPLICATION, FORM 'A',UNLESS" RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY (�/