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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z 90 MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 P MANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED 111 5 W FACILITY/SITE NAME WHERE TANK IS INSTALLED: + e. FARM TANK-YES❑ NO N CAD I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N A. OWNERS TANK ID# R. MANUFACTURED BY: Co C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS /SZ 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑2 P LEUM B. C ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL F-13 CHEMICAL PRODUCT OIL ❑ 1 PR DUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ 60 EMPTY ❑95 UNKNOWN 2 WASTE ❑ 7 METHANOL FE r99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# ��f,�/,j C.A.S.#: b Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLEWAUED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ET-1 STEEL/IRON 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEELCIADW/RBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑ B 100%METHANOL COMPATIS E FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER UNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ SUNING LINING E��IUNEO ❑ MATERIAL COMPATIBLE WITH 100%METHANOL? Ej YES NO 990THE95 RN D. CORROSION ❑ i POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONEUNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFASOVEGROUND, U IFUNDER ROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION 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 U i STEEL/IRON A U 2 STAINLESSSTEEL 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 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL /t�r95 UNKNOWN A U 99 OTHER Am/ V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. �I)D� S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS V P 9 5 PRECISION TESTING P S 7 PRESSURE TESTING P S NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATEDTE UST USED(MO/YR) 2. ESTIMATE QUANTITY OF 3. WASTANK FILLED WITH SUB A F�1�EMAINING IN GALLONS IN Ti}AATERIAL? ❑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&SIGNATURE) DATE A LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# /l FACILITY ID# TTA``NK ID# / � 0 V CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAM PHONE#WITH AREA CODE PERMITN MBER PERMIT APPROVAL DATE PERMIT E(APINATIONDATE CHECK N 7ERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORVB(629me THIS FORM MUST BE ACCOMPANIEDlY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS ARRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY