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STATE OF CALIFOPMA WATER RESOURCES COL BOARD FORM `B': U ERGROUND STORAGE TANK OGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑7 PERMANENTLY ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE V8 TANK REMOVE FACILITY/SITE NAME WHERE TANK IS INSTALLED: N. FARM TANK•YES NO I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY IC A. OWNERS TANK ID If 0 3 B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 4060 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1 CA)),ISNOT MARKED,COMPLETE ITEM D. -4 A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B, G ❑ 1 UNLEADED [P'2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL El-PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ��LLL777 ❑ 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 8 C.A.S.# &1A C.A.S.#: All. TANK CONSTRUCTION MARK OrIE ITEM ONLY IN BOX A,B,C,A D A TYPE OF ❑ 1 UBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEMP1 2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 5TEEUIRON ❑2 STAINLESSSTEEL ❑ 3 FIBERGLASS ❑4 STEEL CND W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ MATERIAL 5 CONCRETE ❑6 POLYVINYLCHLORIDE F-] 7 ALUMINUM E]8100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZEDSTEEL ❑95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR 1 RUBBERUNED ❑2 ALKYD LINING f_13 EPDXY LINING ❑4 PHENOUC LINING LINING ❑5 GLASS LINING [Z;-nNUNED ❑ 95 UNKNOWN ❑ISUNING MATERIAL COMPATIBLEWITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATAON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U`3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A lsTEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL 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 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION S VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 1 NONE P S 95 UNKNOWN P S 99 OTHER ,-'VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST ED(MO/YR) 2. ESTIMATED OU TITY OF 3. WAS TANK FILL WITH N SUBSTANC R NG IN NERT MA E ? ❑yES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF P RJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY IO# TANK ID# 19101114 � G G CURRENT LOCAL AGENCY FACILITY ID APP OED PHONE WITH AREA CODE iE 2S' 000 \ PEA NUMBER PERMIT APPROVALYAft' PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE pECEIPTN BY: FORM B(3-7-6B) THIS FORM MUST BE ACCOMPANY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS ATIMIRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY