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STATE OF CALIFORNIA WATER RESOURCES CONTROk -OARD FORM 'B': UNDERGROUND STORAGE TANK PROD'kAM ;mai TANK A TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. "" 7 tC MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED ( N FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: La! C. YEAR INSTALLED z(l kl D. TANK CAPACITY IN GALLONS: It. TANK ONTENTS 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 DIESEL ❑3 CHEMICAL PRODUCT ❑/OIL 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS HAZARDOUS 80 EMPTY 95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) ❑5 ❑ ❑ D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A TYPE OF F-11 DOUBLE WALLED ❑3 SINGLE WALLED WRH EXTERIOR LINER ❑95 UNKNOWN SYSTEM M-f'SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEUIPON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WNISERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑8 POLYVINYLCHLORIDE ❑7 ALUMINUM F-18100%METHANOL COMPATIBLE FRP MATERIAL ,, ❑9 BRONZE ❑ 10 GALVANIZED STEFL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNED ❑2 ALKYD UNING ❑3 EPDXY LINING ❑4/PHENOLIC LINING C. `INTERIIIOR F-] 5 GLASS UNING ❑6 UNLINED F'96 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH IOD%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTIONCATHODIC 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 1 SUCTION A U 2 PRESSURE A U 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 U 3 LINED TRENCH A U 91 NONE A95 UNKNOWN A U 99 OTHER A U 1 STEFUIRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEEL CLAD W/FRP A U 8190%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 00S5UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 041 P 8 1 VISUAL CHECK P 8 2 INVENTORY REOONCIUATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS 1`LvIJP 8 6 PRECISION TESTING P 8 1 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE W1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WRH Q 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. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# DE ED 16S CURREMT�OCAL�ENCY FACI�IDN "PROVED RROVEDBBY NAME 1y/)• PNONEN WITH AREA CODE PERMITNUUY R PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEECODE RECEIPT* BY: FORMBI6-29-88) THIS FORM MUST BE ACCOMPANIED a A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A C AENT FORMA' HASBEEN FILED DATA PROCESSING COPY