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STATE OF CALIFORNIif WATER RESOURCES CONTROSPARD FORM `B': UNDERGROUND STORAGE TANK PRO RAM TANK TANK PERMIT APPLICATION INFORMATION o<ro COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z a.. If3 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 ERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE gRMANENNK LY FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO 4b. I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY � A. OWNERS TANK ID# B. MANUFACTURED BY: W C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(JI1),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 0 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT .Q b ❑ 1 PRODUCT ❑4 GASAHOL E] 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ASTE ❑ 7 METHANO HER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAMEOF / HAZARDOUS SUBSTANCE STORED&C.A.S.# UD wu �1 ( C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 5 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEBUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOLCOMPATI8LEFRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 5 UNKNOWN ❑ N OTHER C. INTERIOR ❑ 1 RUBBERLINED El2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED ,.1gSkM.IF'OWN ❑ ISLINING MATERIAL COMPATIBLE WITH 100%MEIHANOL? ❑YES ❑NO �THER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE FfT95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDE OUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U / SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE U UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AU2J5 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(_ S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P- 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATEDD41E 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. APPLICANT'S NAME(PRINTED&SIGNAcTUREI_.. DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# Eu = 161 ol OS. CURRENT LOCAL AOrCY FACILITY ID#� APPJpyED BY�N6ME' /^ /O (' PHONE#WITH AREA CODE PERMIT NUMBER (n`/r�j 1('�' K PERMIT APPROVAL DA(lTE_/�+ /`�• PERMIT/I EXPIRATION DATE CHECK# PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: 1 FORM B(6-2s-ee) THIS FORM MUST BE ACCOMPANIED BY AFACILITY/SITE APPLICATION, FORM 'A',UNLESS A RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY