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STATE OF CALIFORN WATER RESOURCES CONTF BOARD FORM B': UNDERGROUND STORAGE TANK PROGRAM ` TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. -- Z 10 MARK ONLY ❑ 1 NEW PERMIT rl 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑7 PENAWNTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT F1 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE VnLefANK REMOVEDId cis FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES�v NO ❑ IV W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY W A. OWNERS TANK ID# o� U MANUFACTURED BY: ct X. 0 C YEAR INSTALLED LtD. TANK CAPACITY IN GALLONS: Q, II. TANK TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUMB. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 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 NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK E ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ 1 DOUBLE WALLED SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 NDARY CONTAINMENT ❑ 99 OTHER ❑ 1 SIEELIIRON ❑2 STAIN STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FlBERGLASS REINFOfiCED PLASTIC B.TANK ❑5 CONCRETE ❑fi PoLYVINYL ORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FHP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED ❑95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR 1 RUBBERUNED ❑2 AU(YD LINING 3 EPDXY LINING ❑4 PHENOLIC UNING LINING F-] 5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN [-] ISLINING MATERIAL COMPATIBLE WITH 100AMETHANOL? S ❑ NO ❑99 OTHER D. CORROSION ❑ 1 PoLYEFHLENE WRAP ❑ 2TAR OR ASPHALT ❑ 3M LWMP ❑4 RBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 UNK WN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGR ND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE AU 3 GRA A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED NCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U i STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL HLORIDE(PVC) A U d FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD FRP A U B 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 S I VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING NO 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 GALLONS 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# FACILITY ID# TANK ID# I I I 1 aI0 d 0 CURRENT LOCAL AGENCY FACILITYi APPROVED ME PHONE#WITH AREA CODE PERMIT NUMBER PERMfT APPROVAL DATE /PERMIT EXPIRATION DATE CXECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE I RECEIPT# BY: FORM B(8-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SRE APPLICATION, FORM'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY