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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. (a MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 15 FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK -YES❑ NO [ I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERSTANKIDR B. B. MANUFACTURED BY: ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL C. YEAR INSTALLED i 3 D. TANK CAPACITY IN GALLONS: /0,000 H. TANK CONTENTS IF MAL IS MARKED. COMPLETE ITEM C. IF MAI. IS NOT MARKED, COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED F]2 LEADED E]3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL R 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL �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. R C.A.S. R: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C,& D A. TYPE OF ❑ I BLE WALLED ❑ 3 SINGLE WITH E%TEROR LINER ❑ 95 UNKNOWN SYSTEM Liff 2 SNGLEWALLED ❑ 4 SECONDARYGONTAINMENT ❑ 99 OTHER A U 99 OTHER 1 STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM B 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 98 OTHER A ❑ I RUBBERUNED ❑ 2 ALKYD LINING F-13 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED U 6 CONCRETE ❑ 95 UNKNOWN U 7 STEEL CLAD W/FRP A U ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 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 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 TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATEIRM A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/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 S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 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 3 9I REMAINING IN INERT MATERIAL? ❑ YES [:]NO GALLONS 0101011 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY. AND TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. APPLICANTS NAME (PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY k JURISDICTION k AGENCY N FACILITY ID R TANK ID N 3 9I o 1 o 1 �2-- s 0101011 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE SRIV-TO /4 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE I CHECK• I PERMITAMOUNT I SURCHARGE AMT. I FEE CODE - l-1-lopf FORM B (6 -29 -BB) THIS FORM MUST BE ACCOMPANIED b1 A FACILITY/SITE APPLICATION, FORM 'A', UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY C 10 CJI N C7