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STATE OF CALIFORNI WATER RESOURCES CONTRC- zOARD FORM 'B': UNDERGROUND STORAGE TANK PROURAM TANK TANK PERMIT APPLICATION INFORMATION m COMPLETE A SEPARATE FORM WITH THE FOLLOWINNFORMATION FOR EACH TANK.oe - MARK ONLY ❑ 1 NEWPERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: ti FARM TANK-YES❑ NO O I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: W C. YEAR INSTALLED Li D. TANK CAPACITY IN GALLONS: 0 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,C PLETE ITEM D. IA' A. Zl MOTOR VEHICLE FUEL ❑ 2 PETROLEUMR. C. Ej�Vll UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CAS.# CA.S.#: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,t D A TYPE OF ❑ 1 WALLE' ❑3 SINGLE WALLED WITH DMIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE D ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON E] 2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC I.TANK ID 5 CONCRETE ❑6 POLYWNYL CHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZEDSTEEL ❑ 95 UNKNOWN ❑99 OTHER C.INTERIOR F-11 RUBBER UNED 2 ALKYD LINING F-13 EPDXYLINING E]4 PHENOLICUNING LINING ❑5 GlASSUNING LN 6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE 100%MEOMNOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2T OR ASPHALT ❑3 WNYLWTUP ❑4 FIBERGLASS REINFORCEDF-Anc PROTECTION [:]5 CATHODIC PROTECTION ❑91 NO ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE OUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTIONA U 2 PRE RE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2D0 WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLE STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 6ALUMINUM A U 6DONOR ETE A U 7STEELCLADW/FRP A U 81OD%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 96 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S OR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE LLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED OUANTITY OF3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? DYES ❑ 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# CURRENT LOCAL AGENCY FACILITY 10#� APPROVED BY N ME .y�� PHONE#WITH AREA CODE PERMIT E PERMIT APPROVAL DATE I VRilqEXPIRATION DATE CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE I RECEIPT# BY: 60 FORM B(6-29-88) THIS FORM MUST BE ACCOMY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A C RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY