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STATE OF CALIFORNI' WATER RESOURCES CONTRQ'�OARD FORM B': UNDEOGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. MARK ONLY F-11 NEW PERMIT F-] 3 RENEWALPERMIT DK5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK IC ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: . -50 lk IV FARM TANK-YES❑ NO N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY co A. OWNERS TANK ID# �f e. MANUFACTURED BY: uNk Q� C. YEAR INSTALLED ,, IL D. TANK CAPACITY IN GALLONS: N II. TANK CONTENTS IF(A.1 S MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A ❑ MOTOR VEHICLE FUEL ❑2 PETROLEUM B 1 PRODUCT C 1 UNLEADED 2 LEADED ❑ 3 DIESEL 3 ❑4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 M NO kc. 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,&D A TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER opUNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STMARON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 AAMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL EVUNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBERUNED ❑2 ALKYD UNING ❑ 3 EPDXY LINING ❑4 P OLIC UNING LINING F-]5 GLASS LINING ❑6 UNLINED UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TARORASPHALT F-I 3'W&WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE LrnL.r`m 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 =PUNKNOWN A U 99 OTHER S.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A,,V__O UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 6ALUMINUM A U 6CONCRETE A U 7STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEELS 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 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P _C:116-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 PH I FD WITH GALLONS 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. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE --ECHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RFITIPT N BY: .w 90 c FORM B(6-29-86) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA HAS BEEN FILED DATA PROCESSING COPY