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STATE OF CALIFORNIA' WATER RESOURCES CONTROI 7ARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM m TANKTANK PERMIT APPLICATION INFORMATION ANK. Z COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATIO14 FOR EACH T id MARK ONLY ❑ I NEWPERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CL NK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED N FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: 00 C. YEAR INSTALLED [1A/ I D. TANK CAPACITY IN GALLONS: II. TANK CIATENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS OT MARKED,COMPLETE ITEM D. A. El�1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED [Iff3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑60 EMPTY E]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&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF El I UBLE WALLED F-] 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I MWIRDN ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 MEL CLAD WRBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 IN%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER C. INTERIOR F-1I RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 OLIGUNING LINING F-15 GLASS UNING ❑6 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYLTNLENEWRAP ❑ 2 TAR OR ASPHALT ❑ 3pW&MP ❑4 FIBERGLASSREINFORCEDPUI5NC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE LK95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A703 GRAVITY A U 91 NONE A95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 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 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL 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. U� n PS 1 VISUAL CHECK ZP S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS S 6 PRECISION 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 SUBSTANCE REMAINING IN OALL0148 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. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# o / 010 1 (113 CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE 1L PERMIT NUMBER l_ /KPERMIT APPROVAL DATE PERMIT EXPIRATION DATE " CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE ^xCEIPT �8 ORM B(e-29-B6) THIS FORM MUST BE ACCOMPANIED BY A FACILITYYSITE APPLICATION, FORM 'A',UNLESS A(:URRENT FORMA MAS BEEN FILED .)ATA PR..