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STATE OF CALIFOR►'BA WATER RESOURCES CON- )L BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM .. ' IA � TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 7` C MARK ONLY ❑ i NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE Of INFORMATION F-1 7 PE L ENTLV CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED Q FACILITY/BITE NAVE WHERE TANK IS INSTALLED: /.2`J3 FARM TANK-YES❑ NO ❑ F" I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY ococ A. OWNERS TANK IDE B. MANUFACTURED BY: T� C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A./),IS NOT MARKED,COMPLETE ITEM D. A. ❑ I MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED E]3 DIESEL [:33 CHEMICAL PRODUCT E] 4 OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS EIS 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 A C.A.S.E CA S,E: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A.B,C,A D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXIERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WAILED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER B.TANK ❑ 1 SEB/ ❑2 STAINLESS STEEL E]3 FIBERGLASS E]4 STEEL CIADW/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑5 CONpETE ❑S POLYWM'L CHLORIDE ❑7 ALUMNA ❑9 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVAMZEO STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ I RNBER LINED ❑2&DO UNING ❑ 3 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ❑ISUNM MATERALCOMPATIBLE WITH 100%METHANDL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYETHUE EWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 GATMODICNIOTECTON ❑91 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 21 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 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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 t IVISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURETESTING P 8 91 NONE P 8 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 SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? C]YES [:]NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY E JURISDICTION 8 AGENCY E FACILITY ID E TANK ID E CURRENT LOCAL ADENCY FACILITY ID/ APPROVED BY MAYS ONE E WITH MEA CODE PERMIT HUMBER ,((=/�"'✓ PERMIT APPROVAL DATE PERY"XPOM BATE CNECKI PERMIT AMOUNT SURCHARGE ANT. FEE CODE RECEIPTI BY: FDRMele29-85) THIS FORM MUST BE ACCOMPANR:VBYAFACIUTY/SITEAPPUCATION, FORM 'A',UNLESS A CURRENT FORM'A' HASBEENFILED A DATA PROCESSING COPY