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STATE OF CALIFORNI/ WATER RESOURCES CONTRO' 'OARD FORM `B': UNDERGROUND STORAGE TANK PRO XMAM TANK TANK PERMIT APPLICATION INFORMATION +. ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Ea6HANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED / FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SOSPECIFY 10 A. OWNERS TANK ID* B. MANUFACTURED BY: C. YEAR INSTALLED ✓ D. TANK CAPACITY IN GALLONS: v Il. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 M VEHICLE FUEL ❑2 PETROLEUM D C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL D24SHEMICAL PRODUCT ❑4 OIL PRODUCT ❑4 GASAHOL ❑ 5 J FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOLTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF A �! HAZARDOUS SUBSTANCE STORED 8 C.A.S.N /7�—C�J C.A.S.W All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,0,C,VB D A. TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER NKNOWN SYSTEM ❑2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑1 STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 A-UPAUM ❑B/004 METHANOL COMPATIBLEFRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER ❑ I RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING C. INTERIOR ❑/ UC UNING LINING ❑5 GLASS UNING ❑6 UNLINED LcA4 UNKNOWN ❑ IS UMNG MATERIAL COMPATIBLE WITH 1004 METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETMENE WRAP ❑2 TAR OR ASPHALT ❑3 VIn WRAP ❑4 RBEAGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONEEZJ4'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 U / SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A CbS 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 AU-6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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 5 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS n P S ' P PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER 1, VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST US (MO/YR) 2. ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? E3YES [:] 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 k JURISDICTION* AGENCY* FACILITY ID* TANK ID* m � v / cl Oo CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAPS PHONE N WITH AREA CODE G� a PERMIT NUMBER PERMIT APPROVAL DATE PERtoTEXPIRATI DATE CHECK* PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT* BY: \1 FORM B(s-7-88) THIS FORM MUST BE ACCOMPANI'0M FACILITY/SITE APPLICATION, FORM `A',UNLE NT FORMA' HAS BEEN FILED DATA PROCESSING COPY