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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. MARK ONLY ❑ 1 NEWPERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION n 7yEPMANENTLY CLOSED TANK E� ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE El 8 TANK REMOVED NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO 1NFACILITY/SITE I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IDB Q, B. MANUFACTURED BY: ^I 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. U2 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 8. C. 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 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&C.A.S.B C.A.S.B: A III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,a D A.TYPE OFF-1BLE WALLED F-13 SINGLE WALLED WITH EXTEROR LINER ❑9,5 UNKNOWN SYSTEM LEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER Ef 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM E]B 100%METHANOLCOMPATIBLEFRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2,kKYDUNING ❑3 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑ 5 GLASS LINING 8 UNLINED ❑95 UNKNOWN- w� / ❑IS LINING MATERIAL COMPATIBLE WITH IOD%METHANOL? ❑YES [—]NO /��/ D. CORROSION ❑ 1 POLYEMLENE WRAP ❑2 TAR OR ASPHALT n 3y11NLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHIM IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IFAPP CABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A 1 No A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLEWALLED A U 2 DOUBLEWALLED A U 3 LINED TRENCH A 91 NONE A U 95 UNKNOWN A 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A Vl NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOLCOMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER 1 V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. [Jell P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 6 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. TIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF GALLONS 3. WA TANK FILLED WITH ^ S STANCE REMAINING IN IN MATERIAL? ❑YES [—]NO THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNO LEDGE,IS TRUE AND CORRECT APPLICANPS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION B AGENCY B FACILITY ID B TANK ID B 3 � o vov CURRENT LOCAL AOENOY FACILITY ID N APPROVED BY PHONE N WITH AREA CODE A�� 2,c> PERMIT NUMBER PERM IT APPROVAL DATE P RMIT EXPIRATIdNDATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RFCEIPTN BY: FORM 8(6-29-88) THIS FORM MUST BE ACCOMPANIED A FACILITY/SITE APPLICATION, FORM'A',UNLESS A CUNRENT FORMA HAS BEEN FILED DATA PROCESSING COPY