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STATE OF CALIFORNI WATER RESOURCES CONTRC 10ARD FORM 'B': UNDERGROUND STORAGE TANK PROMRAM TANK TANK PERMIT APPLICATION INFORMATION sm „ COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ z MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ,T 10 2 IN ONE ITEM � ❑ TION E] 7 PERMANENTLY CLOSED�ALNK ❑ INTERIMPERMIT ❑4 AMENDED PERMIT ED TEMPORARY TANK CLOSURE �NK REMOVED U-I FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1 w LI7� r� FARM TANK-YES❑ NO IV I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# I 1q, �C`IOa B. MANUFACTURED BY: Fr C. YEAR INSTALLED - D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A_ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS j ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED A C.A.S.# C.A.S.#: - III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER Ef 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ ❑ 7 ALUMINUM MATERIAL 5 CONCRETE 6 POLYVINYLCHLORIDE ❑ ❑8 f00%METHANOI COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RUBBERLINED ❑ 2 ALKYD LINING ❑3 EPDXYLINING ❑ 4 PHENOLIC LINING LINING ❑5 GLASSUNING ❑6 UNLINED UNKNOWN ❑ IS LINING MATERIAL COMPATIBLEWITH 100%MEIHANOL? ❑YES ❑ NOOTHER- D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONENKNOWN ❑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 AU 3 GRAVITY A U 91 NONE AQY UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE. A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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 I VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 5 3 VADOOSE WELL S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P B 6 PRECISION TESTING P 5 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIMATED DATE LAST USED(MO/Vfl) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑yES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAM (PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 06 I L E= I 0 I O I d CURRENT LOCAL AGENCY FACILITY ID# /-1 I CL APPROVED BY NAME CjrjHONE N WITH AREA CODE `J _ (_p PERMIT NUMBER PERMIT APPROVAL DATE PERMR EXPIRATION DATE CHECK N PERMIT AMOUNT CURCHARGE AMT. FEE CODE "-`^II{pTN BY: FORM B S 29-63) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED - DATA PROCESSING COPY