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STATE OF CALIFORNIf WATER RESOURCES CONTRO' OARD FORM `B': UNDERGROUND STORAGE TANK PROMAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - � MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS SiLz ONE ITEM F--] 2 INTERIM PERMIT F-] 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: V, ---- C FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY If 1© A. OWNERS TANK IDN B. MANUFACTURED BY: C. YEAR INSTALLED U 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. C9 II A. ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B, C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL �HEMICAL PRODUCT ❑ 4 OILPRODUCT ❑ 4 GASAHOL ❑5 J EL ❑6 AVIATION GAS [:] 5 HAZARDOUS 80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.W 3 =III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,B D A. TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER NKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARYCONTAINMENT ❑99 OTHER ❑ I STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4STEEL CLAD W/FIBERGLASS REINFORCED PLASM B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALU IN ❑8180%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL igjArUNKNOWN ❑99 OTHER F-11 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHE LINING C. INTERIOR ❑5 GLASS UNING ❑6 UNLINED UNKNOWN ❑ IS UNING MATERIALOOMPATIBLEWRH 180%METHANOL? ❑YES ❑ NO ❑99 OTHER 0, CORROSION ❑ 1 POLYETHLENEWRAP ❑2TAR OR ASPHALT ❑ 3 VI P ❑ 4 FIBERGLASS REINFORCED PLA6RC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE L LfS 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 AJ B. CONSTIIUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A(UT15 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C, MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL Al2>5 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 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE- P S 95 UNKNOWN P S W OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LW/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH 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. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAM PHONE N WITH AREA CODE v PERMIT NUMBER PERMIT APPROVAL DATE PERMIf EXPIRATION ATE CNECKN PERMIT ANOUNT SURCHARGE AMT. FEE CODE RECEIPT BY: FORM B(3-7-w) THIS FORM MUST BE ACCOMPAN FACILITY/SITE APPLICATION, FORM `A',UNLE NT FORMA' HAS BEEN FILED DATA PROCESSING COPY