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STATE OF CALIFORN WATER RESOURCES CONTF . BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION m . COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. [FACILITY/SITE ARK ONLY ❑ I NEW PERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK FC ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ANK REMOVED Q NAME WHERE TANK IS INSTALLED: FARM TANK-YES NO 71 N 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY F'+ A. OWNERS TANK ID# 0 B. MANUFACTUREDBY: u C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A MOTOR VEHICLE FUEL 2 PETROLEUMB. C. El UNLEADED 2 LEADED DIESEL 3 CHEMICAL PRODUCT /OIL 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 8 CAS.# CAS.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,A D A TYPE OF ❑ I BLE WALLED 3 SINGLE WALLED WITH EXTERIOR UNER 95 UNKNOWN SYSTEM ❑2 SING 4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON :j2 STAINLESS STEEL [:]3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL B.TANK 5 CONCRETE 6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑6 1011%METHANOL COMPATIBLE FRP 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER C. INTERIOR ❑ 1 RUBBER UNED ALKYD LINING ❑3 EPDXY LINING 4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 NED ❑95 UNKNOWN IS UNING MATERIAL COMPATIBLE WITH 100% NOL? YES ❑NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHIENE WRAP 2 TAR OR ASPHAL ❑ 3 VINYL WRAP F-1 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF DERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE AN 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 XLINED 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 PbbkVIWL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL LA0 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 I"RhIgAIRY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONI ONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING 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 OFBALLONB 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? Ej YES EJ 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 8 SIGNATURE) DATE �i LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID k m0 1 c o CURRENT LOCAL AGENCYFACILRYID# APPROVED BY NAME 7�t PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PEAMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTN BY: FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY