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STATE OF CALIFORNIf WATER RESOURCES CONTRO' 'OARD 4s•.v:V r•� FORM `B': UNDEFRbROUND STORAGE TANK PROMRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN2 INFORMATION FOR EACH TANK. _tt Z MARK ONLY ❑ 1 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 ❑8 TANK REMOVED r1 FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO .� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY IV A. OWNERS TANK ID# r B. MANUFACTURED BY: -� C YEAR INSTALLED f" D. TANK CAPACITY IN GALLONS' II. TANK 9ONTENTS. IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. gI MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B, C. ❑ 1 UNLEADED ❑ 2 LEADED EIKDIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OILPRODUCT ❑ 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.# G A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLEWALLED 4 SECONDARY CONTAINMENT [_] 99 OTHER 1 STEELIIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM F—] 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR E71 RUBBER LINEU E] 2 ALKYD LINING 3 EPDXY LINING F—] 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TABOR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTIDN 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 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION Afu3 17 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE 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 A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 6 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2- ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E] 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 IID# j TANK IIDD## ,= I I -] -- I ET I I I I Eo:lo CURRENT LOCAL AGENCY FACILITY ID# APPROVED 13Y 7M.!,M.!, !I � J� f ; PHONE#WITH AREA CODE I // �f PERMIT NUMBER PERMIT APPROVAL DATE 0ERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. 'FEE CODE REQ=EIPT# BY: FORMS(6-29-ea) THIS FORM MUST BE ACCOMPANIED A FACILITY/SITE APPLICATION, FORM `A',UNLESS A RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY Y