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STATE OF CALIFORNIA WATER RESOURCES CONTROL F RD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANKTANK PERMIT APPLICATION INFORMATION TANK. COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH Z Ic 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 TANK REMOVED HJ W i FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO ❑ fV N 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 0 A. OWNERS TANK ID# B. MANUFACTURED BY: L C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Vl. 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 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL ❑ I PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY 4SUNKNOWN ❑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.# L-- C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,S,C,&D A TYPE OF ❑ I DOUBLE WALED ❑3 SINGLE WALLED WITH EXTERIOR UNER UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT 99 OTHER ❑ 1 STEELARON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGUSS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ M F-]81DDAMETKANOL COMPATIBLE FRP MATERIAL F]9 BRONZE ❑10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER UNED ❑2 ALKYD UNING ❑3 EPDXY LINING ❑4 PHEN IC UNING LINING ❑ 5 GLASS LINING ❑6 UNLINED UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IDD%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VI ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A FABOVEGROUND. 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(9-95 UNKNO A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U 91 NONE U 95 UNK OWN U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 6 A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U CRETE A U 7 STEELCLADW/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A UNKNO 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 S I VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P UN 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 INERT MATERIAL? E]YES ❑ 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 S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# a? U I o CURRENT LOCAL AGENCY FACILITY 1110 APPROVED BY NAME PHONE N WITH AREA CODE LLT PERMIT NU ER /1/T� PERMIT APPROVAL DATE PERMITEXPIMTION DATE CNECKN PERMMAMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORMR(6-29-98) THIS FORM MUST BEACCOIWMID BYA FACILTEY/SFTE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HASSEENFILED DATA PROCESSING COPY