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STATE OF CALIFORNIA' WATER RESOURCES CONTROI ,OARD FORM `B': UNDEnROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Id'CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK 10 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED D J FACILITY/SITE NAME WHERE TANK IS INSTALLED: m FARM TANK-YES❑ NO N 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 0 (0 A. OWNERS TANK ID# B. MANUFACTURED BY: d. N C. YEAR INSTALLED 't D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑1 MOTOR VEHICLE FUEL ❑/ETROLEUM B C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL F-13 CHEMICAL PRODUCT Z4 OIL 1 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 NAMEOF HAZARDOUS SUBSTANCE STORED&C.A.S.# r7" B_ C.A.S.#: III. TANK CONSTRU TION MARK ONE ITEMONLYINBOXA,B,C,aD A. TYPE OF 1 DOUBLEWALLBT ❑3 SINGLE WALLED NTH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLEWAUED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 SMARON ❑2 STAINLESS STEEL FIXFIBERGLASS ❑4 STEEL CLAD W/RBERGIASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE E]6 POLYVINYLCHLORIDE 7 ALUMINUM ❑6100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 93 OTHER C. INTERIOR [:] 1 RUBBERUNED E]2 ALKYD LINING F-]3 EPDXY LINING ❑4 PHENOLIC UNING LINING 5 GLASSUNING ❑6 UNUNED ❑95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES NO 99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTI PROTECTION F]5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN OTHER s IV. PIPING INFOR%jt2lill CIRCLE A IF ABO# ROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A 1 SUCTION PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U OUBLE 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(PV4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%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 6 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WEL P 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH GALLONS SUBSTANCE REMAINING IN 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 B SIGNATURE) DATE LOCAL AGENCY USE ONLY COO`U IIN�TYY# II JURISDICTION# AGENCY# FACILITY ID# TANK ID# �-�-'--fes CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE USPOS31a171'70 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRAfION DTE CHECK# PERMIT AMOUNT _SURCHARGE AMT. FEE CODE RECEIPT# BY: C-77 FORMB(6s9-881 THIS FORM MUST BE ACCOMPANI AFA�dY/SITE APPLICATION, FORM'A',UNLESS A RENT�ORM'A' HAS SEEN FILED DATA PROCESSING COPY