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STATE OF CALIFORNIO WATER RESOURCES CONTRO ARD FORM `B': UNDERGROUND STORAGE TANK PRO AM „o TANK TANK PERMIT APPLICATION INFORMATION ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. °"— z IC MARK ONLY 01 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED Of FACILITYISITE NAME WHERE TANK IS INSTALLED: , FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY W GALLONS: �} II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. FLj'1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL Pill,PRODUCT ❑ 4 GASAHOL ❑ 5,LET FUEL ❑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 NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# Al—flC.A.S.#: ILL, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEMV?r2SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEELIIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE 717 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL .11 ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED '�e6 KYD LINING F-] 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR F-] 5 GLASS LINING LINED ❑ 95 UNKNOWN LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR CR ASPHALT ❑ VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE � '°UNKNOWN ❑ 99 OTHER IV. PIPING INFORMA N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A 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 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 91 NONE C. MATERIAL A U 5 ALUMINUM A W V 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 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P 3 4 ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS R S 6 PRECISIONTESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P $ 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LASI USED(MO/YR) 2. ESTIMATE QUANTITY OF 3.WAS TANK JILLED WITH SUB E MANING IN GALLONS �/�'INERT�/ya AL? ❑ YES [:] NO THIS FOR �HABF�ENCOMPLETED UNDER PENALTY F PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# ,/� FACILITY]/ID# TTA�jNK IDD# UE CJ & J Fo- L/ o 1,�jl CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAM PHONE M WITH AREA CODE 1-2" t PERMIT NUMB01 PERMIT APPROV L D PERMIT E IRATION DATE CHECK Of PERMIT AMOUNT SURCHAR E AMT. FEE CODE ECEfPT K BY: FORM B(6-29-8a) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM `A',UNLESS A CURRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY