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STATE OF CALIFORN# . WATER RESOURCES CONTP BOARD FORM B': UNDERGROUND STORAGE TANK PRO-LiRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. pa MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED pTANK ONE ITEM ❑ 2INTERIM PERMIT E-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE f TANK REMOVED V / FACILITY/SITE NAME WHERE TANK IS INSTALLED: O (J FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY IQ A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: El W 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A-1),ISNOT MARKED,COMPLETE ITEM D. A A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ' LfZ3 CHEMICAL PRODUCT ❑ 4 OIL le PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS 1-15 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL WOTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CAS.# �a Y`H r Th;ri t7e-r C.A.S.#: LOT =III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNEP 95 UNKNOWN SYSTEM ❑2 SINGLE WAILED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑1 STERARON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FOP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL L %UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBERUNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑ 5 GLASS UNING ❑6 UNLINED UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE �5 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 9 OTHER (.t B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 1 DO%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 095 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 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P B 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING 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 OFGALLONS 3.WAS TANK FILLVED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑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 LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# CILITY ID TANK ID# U11 L3J ol d CURRENT LOCAL AGENCY FACILITY' APPROVED BY NAME 1/./1 PHONE#WITH AREA CODE -- f0 E 9/;L g-8 FIC. PERMIT NUMBER PERMITAPPROVM.OAllf I PERMIT EXPIRATION DATE CNECK k PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: CHI —P� FORM B(3-7-85) THIS FORM MUST BE ACCOMPANI9IYB�A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORMA' NAS BEEN FILED l DATA PROCESSING COPY 74