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STATE OPCALIFORNI/ WATER RESOURCES CONTROi@bARD � FORM 'B'. UNDERGROUND STORAGE TANK PROGRAM SIA _ a TANK,. : TANK PERMIT APPLICATION INFORMATION �?� ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z 3 U MARK ONLY I NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLQSE&TA7 ONE ITEM 2 INTERIM PERMIT ❑{AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED/ ./ FACILITY/SITE NAPE WHERE TANK IS INSTALLED: `• 7 / ry`, ,/yyv N P ji"i°-di C, FARM TANK•VES[Z3-NO ❑ N 6 TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY C.O A OWNERS TANK ID E / B. MANUFACTURED BY: CAD C.YEAR INSTALLED 'I D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(Al),IS NOT MARKED,COMPLETE ITEM D. A 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. I UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT E:] /OIL 6 PRODUCT ❑ 1 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ 60 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 6 CA.S.M C.A.S.It III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A.B,C.AD A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED MTH WERIOR UNER ❑95 UNKNOWN SYSTEM. ❑2 SINGLE WALLED ❑1 SECONDARY CONUINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESSSTEEL ❑3 FIBERGLASS E]1 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL.. B.TANK '. ..r75 CONCAEIE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B tDAMETHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ I RUBBERUNED ❑2 AIM LNNG ❑3 EPDXYUMNG ❑/PHENOLIC LINING LINING ❑5 GLMUMNG ❑6 UUNED ❑95 UNKNOWN . ISJNNO WTEAULCdIPATIBLE WITH 10011 ME7WVEK1 ❑YES ❑NO [_ 99 OTHER D.CORROSION ❑ 1.POLYERILBMEWRAP ❑2 TAR OIL ASPHALT ❑3 VINYL WRAP ❑1 FlBEAGUSS REINFORCED PLASTIC PROTECTION, ❑5 G7H(1DIC PROTECTION ❑SIL NONE ❑95 UNKNOWN —]99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE I A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEUIRON A U 2 STAINLESSSTEFL A U 3 POLYVINYL CHLORIDE(PVC) A U I NBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U 6 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 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 t 1 VISUAL CHECK P t 2 INVENTORY RECONCILIATION P t 3 VAOOSE WELLS P S I ELECTRONIC MONITOR P 0 5 GROUND WATER MONITORING WELLS 1 1 PRECISION TESTING P t 7 PRESSURE TESTING P t 91 NONE P S 95 UNKNOWN P 6 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED GUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑yE5 ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPUCANT'S NAME(PRINTED L SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY E JURISDICTION E AGENCY Y FACILITY 10 E TANK ID 1 CURRENT LOCAL AGENCY FACILITY ID 1 APPROVED BY NAME PHONE 1 WITH AREA CODE PEAMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE l A CHECK 1 PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT Y ✓BY:✓ FGRMaL6.2s-w) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HASBEENFILED