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STATE OF CALIFORNI/' WATER RESOURCES CONTRO ZOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. �" Z LO MARK ONLY F-1I NEWPERMIT ❑ 3 RENEWALPERMIT [:] 5 CHANGE OF INFORMATION [:]7 PE NENTLYCLOSEDT K ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT E:] 6 TEMPORARY TANK CLOSURE TANK REMOVE O N FACILITY/SITE NAME WHERE TANK IS INSTALLED: �� O/C G✓ FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: O YEAR INSTALLED 8 D. TANK CAPACITY IN GALLONS: O O II. TANIS C ENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A.1), S NOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. ❑ 1 UNLEADED ❑2 LEADED Ep'3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL I PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS 5 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&C.A.S.# C.A.S.It III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ 1 D011SLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SIN WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER f STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER UNED ❑2 AM ❑ 3 EPDXY LINING 4 P UC LINING LINING ❑5 GLASS LINING ❑6 UNLINED 5 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH IOD%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2TAR OR ASPHALT ❑ 3 WRAP ❑1 FIBERGLASS REINFORCED PIASRC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INF0RMA ION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A 1 RUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE 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 JL 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U)35 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST SE CIRCLED. P 8 1VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSEWELLS P 8 4 ELECTRONIC MONITOR P 8 5GROUNLYWATR JON470PING WELLS P S 6 PRECISION TESTING P 8 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 G INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE LS TRUE AND CORRECT, APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION M AGENCY# FACILITY ID# TANK ID# 0011 15 / OG I v I VI CURRENT LOCAL AGENCY FAC/IL�ITY IO# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER i ' PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE .RECEIPT# BY: _7, FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SRE APPLICATION, FORM'A',UNLESS RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY