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STATE OF CALIFORNI ' WATER RESOURCES CONTRC_)OARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION sm COM ETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. a, MARK ONLY Upo[NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO 1 1 ONE ITEM TERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: E FARM TANK-YES❑ NO .7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 10 A. OWNERS TANK ID N )I B. MANUFACTURED BY: C. YEAR INSTALLED lqxD. TANK CAPACITY IN GALLONS: U dD D II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. �-+ A. ffl MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BO 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 C.A.S.N C.A.S.N: Kill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,8 0 A.TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM f 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER �I STEELIIRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC S.TANTERIAL ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B IOD%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR F-11 R9BKRUNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING [--]4 PHENOUC LINING LINING ❑5 GMLINING Eq-16NUNED ❑95 UNKNOWN ❑ IS UMNG MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑ 99 OTHER D.CORROSION ❑ I PMYETHLENEWRAP TAA OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC 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 U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A Wl SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C MATERIAL A U 5 ALUMINUM AU B CONCRETE A U 7 STEEL CLAD W/FRP A U B 10096 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 3 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 3 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 IST USED(MO/YR) 2. ESTIMATED I UANTITY OF 3, WAS TANK LL D WITH SUBST R MINING IN GALLONS INER RI 7 E]YES [:] NO THIS FO HAS BEEN COMPLETED UNDER PENALTY OF ERJURY.AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION M AGENCY N FACILITY ID N TANK IO N m � o 3 r D o CURRENT LOCAL AGENCY AGILITY ID N APP O E N E. PH NE N WITHA DEQ PERMIT NUMBERP R IT R ALD TE PERMIT EXPIRATIOND j I CHECK N PERMIT AMOUNT SURCHA E A . FEE CODE RECEIPT N BY: FORM B O -BB) THIS FORM MUST BE ACCOMPANIF, e A FACILITY/SITE APPLICATION, FORM 'A',UNLESS AtTKRENT FORM'A' HAS BEEN FILED