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`M1YY'-Nr�^lilviti :Lfpx�i1�."iR.�llyi,npV'.. �� , STATE OF CALIFORNI/1 WATER RESOURCES CONTRO' DARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ z 0 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM [-]2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE B TANK REMOVED I CA FACILITY/SITE NAME WHERE TANK IS INSTALLED: a E. FARM TANK-YES❑ NO ca I. TANK DESCRIPTION COMPLETEALL ITEMS-IF UNKNOWN-SO SPECIFY -4 A. OWNERS TANK ID# 7-D B. MANUFACTURED BY: w C. YEAR INSTALLED 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 ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT OIL 1 PRODUCT ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ��ASTE ❑ 7 METHANOL ❑99 OTHER(]DESCRIBE IN ITEM D,BELOW) D IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE 8 C.A.S.# w 1..S t�. Of, / C.A.S.#: 05 Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C.&D A.TYPE OF ❑�1 D1OUBLEWALIFD ❑ 3 SINGLE WALLED WITH DMIOR LINER ❑95 UNKNOWN SYSTEM �Z SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER [jj TEELAAON ❑2 STAINLESS STEEL ❑3FIBERGLASS ❑4STEELCLAO W/FIBERGLASS REINFORCED PLASTIC 8. TANK ❑5 CONCRETE _ 6 POLYVINYLCHLORIDE ❑7 ALUMINUM B 10D%METHANOL COMPATIBLE FRP MATERIAL E]9 BRONZE ❑ 10 GALVANIZED STEEL NKNOWN ❑ MOTHER C. INTERIOR ❑ 1 RUBBER LINED 1-1 2 ALKYD LINING Eer3 EPDXY LINING 4 PHENOLIC UNING LINING ❑5 GLASS LINING ❑6 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 10D%METHANOL? VES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TM OPASPHAL7 ❑3 NYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, 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 Agj,,�5 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 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE(PVM A U 4 FIBERGLASSPIPE A U 91 NONE 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 GALVANIZED STEEL A co 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 8 1 VISUAL CHECK & 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS .YT / P 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF3. WAS TANK FILLED WITH GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES E] 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 LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# O / l D 7 D 0 CURRENT LOCAL AGENCY FACIL'ID# APPROVED By �l'1'+ PHONE#WITN AREA CO PERMIT NUMBER PERMIT APPROVAL DA !PY Y PERMIT EXPIRATION DATE CHECK k PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6.29-88) THIS FORM MUST BE ACCOMPARIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLES A RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY