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. u ` M1 STATE OF CALIFORN18 WATER RESOURCES CONTROOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK c'- TANK PERMIT APPLICATION INFORMATION Z ` COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CJ.OBED"�WK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE / FACILITY/SITE NAME WHERE TANK IS INSTALLED: ��j FARM TANK-YES NO rV (A) I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 9s3� � A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED u k D. TANK CAPACITY IN GALLONS: II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED, MPLETE ITEM D. C. 1 UNLEADED 2 LEADED 3 DIESEL A. 1 MOTOR VEHICLE FUEL El PETROLEUM B. ❑ ❑ ❑ 3 CHEMICAL PRODUCT [:] METHAN 4 OIL 1 PRODUCT ❑ 4 METHANOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS E] 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑7 MOL ❑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.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ '"AL ED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINUGB WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 Fl GLASS ❑ 4 STEEL CLAD WNISERGLASS REINFORCED PLASTIC B. TANK F-15 CONCRETE ❑ 6 POLYVINYLCHLORIDE LUM11' ❑ B 100%METHANOL COMPATIBLE FRP MATERIAL E] 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER F] 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING n 4ynENOUC LINING LINING ❑5 GLASS LINING 6 UNUNED 9 C. INTERIOR 5 UNKNOWN ❑ ❑ ISLINING MATERIAL COMPATIBLE WITH 100%METRANOL9 ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT 3 NYLWRAP E]4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMA ION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A W 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 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 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 91 NONE C. MATERIAL A U 5 ALUMINUM A CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 5 UNKNOWN A U 99 OTHER V. LEAK DETECTION S TEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. S 1 VISUALCHECK P S 2 INVENTORY RECONCILIATION P 8 3VADOSEWELLS P 3 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS GP S 6 PRECISION TESTING P 7 PRESSURE TESTING P S 91 NONE P S 95 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 FILLED WITH SUBSTANCE REMAINING IN GALLONS 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# rol G d y G UU I / CURRENT LOCAL AGENCY FACILITY ID X ✓ APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER �// C• S PERMIT APPROVAL DATE PERMIT EXPIRATION DATE L CNECKM PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY.. FORM B(6-29-88I THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM W HAS BEEN FILED DATA PROCESSING COPY