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STATE OF CALIF.. . ORNIA 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. MARK ONLY 0 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED`7AN ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FFjj11 FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO ty I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN- NQ SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: •I C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: N II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. w Kli A. ❑ i MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL ❑ I PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 KNOWN ❑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.# CA.&W 111. TANK CONSTRUCTION MARK ONE ITEM ONL IN BOX A,B.C,A D A TYPE OF ❑1 DOUBLE WALLED ❑ 3 SNGLE WALlE WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CO Alt MENT ❑99 OTHER ❑ 1 STIRIIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETEMATERIAL ❑6 POLYVINYL CHLORID ❑7 ALUMINUM ❑S 19996 METHANOL COMPATIBLE FRP ❑9 BRONZE ❑10 GALVANIZED STEEL %UNKNOWN ❑%OTHER ❑ 1 RUBBERLINED ❑2 ALK1'O LINING 3 EPDXY LINING ❑/PHENWCUNING T C.INTERIOR ..i LINING ❑5 GLASS LINING ❑6 UNLINED ❑%UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑NO ❑%OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE E]% NKNOWN E]%OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IFUN RGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A 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 4 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 9/ NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOLCOMPATIBLEFRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SEC NDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 5 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 5 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLA 1. ESTIMATED DATE LAST USED(MONR) 2. ESTIMATED QUANTITY OFGALLONS ED 3.WAS TANK FILLWITH SUBSTANCE REMAINING IN INERT MATERIAL? [-]YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO HE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# -30 16 1115111D 10 10 CURRENT71.AGENCY FACILITY IDN APPRO BY NAME PHONE N WITH AREA CODE , PERMIT N MBER PERMIT APPROVAL DATE RMR EXPIRATION DATE CHECK# PERMIT AMOUNTSURCHARGE AMT. FEE CODE RECEIPTN BY: FORM 8(6-29-88) THIS FORM 'A',UNLBEEA CURRE 'ORM W HAS BEEN FILED DATA PROCESSING COPY