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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑1 NEW PERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLYC K ONE ITEM 0'2/INTERIM PERMIT /AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVE FACILITY/SITE NAME WHERE TANK IS INSTALLED: ) FARM TANK-YES Ll NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY IO A. OWNERS TANK ID R B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: D 11. TANK CONTENTS IF(Al),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. 0 A. ❑ 1 MOTOR VEHICLE FUEL [Er2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑4 OIL ❑'1 PRODUCT ❑4 GASAHOL ❑5_J EL ❑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 NAMEOF HAZARDOUS SUBSTANCE STORED&C.A.S.N C.A.S.#: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B.C,A D A TYPE OF ❑ 1 BLE WALLED ❑3 SINGLE WALLED NTH EXTERIOR UNER ❑95 UNKNOWN SYSTEM 2 SINGLE WAllID ❑4 SECONDARY CONTAINMENT 99 OTHER 1 STEELIIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVIWLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑%OTHER ❑ 1 RIBBBIUNED ❑2 DUNING F-13 EPDXY UNNG ❑ 4 PHENOLIC LINING C. INTERIOR 5 GLASS UNING 6UNLINED ❑95 UNKNOWN LINING ❑ ❑ISUNINGMATERMLCOWATIBLEWITH100%METH014OL9 ❑YES 0 NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLLIE WRAP ❑2TAR OR ASPHALT ❑ 3VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE %UNKNOWN ❑ 99 OTHER IV. PIPING INFORMA ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE FMAERIIALI 1 PRESSURE A U 3 GRAVITY A U 99 OTHER A U DOUBLE WALLED A U 3 LINED TRENCH 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 5 ALUMINUM A 8 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U 95 UNKNOWN A U 99 OTHER IX LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 5 I P 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS l 8 PRECISION TESTIN P S 7 PRESSURETESTING P 8 91 NONE P 8 95 UNKNOWN P S W OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DAE UST USED(MO/YR) 2. ESTIMATED UANTITY OF 3. WAS TANK fILLED WITH AlA SUBST NC R AINING IN INERT M ? ❑YES NO GALLONS THIS FOR HAS BEEN COMPLETED UNDER PENAL OF ERJURY,AND TO THE BEST OF MY KNOWLED ,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY A FACILITY ID# TANK ID M D01 l -? I �-t 3 Do 16 CURRENT LOCALA ENCY FACILITY ID# APPR E B NAME PHONE#WITH AREA CODE as 2� wL PERMIT NUMBER PER R VAL DA PERMIT EXPIRATION DATE 1 CHECK# PERMIT AMOUNT SURCHAIWE AMT. D/C^I FEE CODE RECEIPT# BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANII 'A FACILITY/SITE APPLICATION, FORM'A',UNLESS T FORMA' HAS BEEN FILED " DATA PROCESSING COPY