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STATE OF CALIFORNIJA WATER RESOURCES CONTROL 10ARD FORM 'B': UNDEftROUND STORAGE TANK PROUPIAM „may TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEWPERMIT ❑3 RENEWALPERMIT ® CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: C FARM TANK-YES❑ NO Z I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 117 A. OWNERS TANK IDN B. MANUFACTURED BY: urt C.YEAR INSTALLED15SI-3D. TANK CAPACITY IN GALLONS' IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. tV A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT bj�6 OIL IK1 PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF 1 HAZARDOUS SUBSTANCE STORED&C.A.S.N r_ 01, 1 C.A.S.W O All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.8,C,&D A TYPE OF ❑ 1 DOUBLEWAL ED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ®1 SINGLE WALLED ❑4 SECONDAWCONTAINMENT ❑99 OTHER ®"f STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEELCIADW/RBERGLASSREINFORCED PLASTIC 8.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLOROE ❑7 ALUMINUM ❑6 19916 METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C INTERIOR ❑ 1 RUBBERUNIED ❑�/2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING 6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP J ' TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED RAM 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 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A&;)95 UNKNOWN A U W OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL 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 GALVANIZEDSTEEL A©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 S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P'b6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 8 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. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION 8 AGENCY N FACILITY ID N TANK ID N CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE 0 WITH AREA CODE ' 00l- S 7 -.�KJ--s PERMIT NUMBER PERMITAPPROVALDATE PERMIT EX NDATE CNECKN PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPTN BY: FORM B(3-7-w) THIS FOAM MUST BE ACCOMPANIED BY A FACILRY/SRE APPLICATION, FORM 'A',UNLESS CURRENT FDRM'A' NAB BEEN FRED DATA PROCESSING COPY