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STATE OF CALIFORNI/' WATER RESOURCESCONTRO' 'OARD FORM 'B': UNDEVGROUND STORAGE TANK PROGMAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED U/ FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO 3 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 A. OWNERS TANK IDK B. MANUFACTURED BY: C. YEAR INSTALLED l.' G D. TANK CAPACITY IN GALLONS: / U II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. 0 A. ❑ 1 MO RVEHICLE FUEL F-12 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 4 GASAHOL ❑5 JEf FUEL ❑6 AVIATION GAS [-] 5 HAZARDOUS ❑SO EMPTY [-]95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL 7HER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&GAS.# C.A.S.W xIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 MEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMI W ❑ 8 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZE STEEL NKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RUBBER UNE ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHE LINING LINING ❑5 GLASS UNING ❑8 UNLINED UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH IW%METHANOL? ❑YES ❑NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑ 2 TARORASPHALT ❑ 3 VINYL P ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE LjAnNKNOWN ❑ 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 V B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH 5 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM ASU �6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL M U 25 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 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS I' P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 3 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1, ESTIMATED DATE LAST u5 D(MO/YR) 2. ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH OALLONB N /� SUBSTANCE REMAINING IN 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3H I C)I CD1 Iglct3 I nc) o8 CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAPE PHONE N WITH AREA CODE Ca�T7( g� PERMIT NUMBER PERMIT AIWROVALNDATE PER IT EXPIRATIO ATE ro CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORMe(3-7-ea) THIS FORMYIISTBEACCOMPAN wFACILITY/SITE APPLICATION, FORM 'A',UNLE NT FORMA' HAS BEEN FILED DATA PROCESSING COPY