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STATE OF CALIFORN! WATER RESOURCES CONTRC 90ARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION ®' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ® CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED / FACILITY/SITE NAME WHERE TANK IS INSTALLED: 5 SA. ' .L—. FARM TANK-YES❑ NO &cr Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY R A. OWNERS TANK ID# D. MANUFACTURED BY: aA C. YEAR INSTALLED ' D. TANK CAPACITY IN GALLONS: w II. TANK CONTENTS IF(a1),IS MARKED,COMPLETE ITEM C.IF(A.1),18 NOT MARKED,COMPLETE ITEM D. IV A. �MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED Q1 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL Nill PRODUCT ❑ 4 GASAHOL ❑5 JET 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 8 C.A.S.M G'A'S'M. :III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.S D A TYPE OF ❑T��1,.1�DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ®'2 SINGLE WALLED ❑4 SECOMIARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEELIIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL OOMPATIBLEFRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL �UNKNOWN ❑99 OTHER F-11 RUBBERLINED ❑ 2 ALKYO LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR LINING ❑S GLASS LINING ©fi UNLINED ®'95 UNKNOWN ❑ IS UMNG MATERIAL COMPATIBLE WITH Look METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENEWMP 2TARORASPHALT ❑3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTE 91 NONE &115 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIR A IF ABOVE GROUND, U IUNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION � ACV2 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 %UNKNOWN A U 99 OTHER A U 1 STEELPRON A U 2 STAINLESS STEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FIBERGLASS PIPE C.MATERIAL A U 5 ALUMINUM Ay�Uu'6 CONCRETE A U T STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL V 95 UNKNOWN A U W OTHER V. LEAK DETECTION SYSTELf CIRCLE P FOR PRIMARY,OR 8 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 1 VISUAL CHECK OS f INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND W R NATO L P 8 PRECISION TESTING P B PRESSURE TESTING P B 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 E] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY A JURISDICTION M AGENCY M FACILITY IDM TANK ID M M = = 0o I moo 14 CURRENT LOCAL ARE Y F IIITY IDM APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMITEXP DATE CNECKN PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEl" BY: FORMB(3-7-88) THIS FORM MUST BE ACCOMPANIELMTAFACILITY/SITE APPLICATION, FORMA,UNLESS FORMA' HAS BEEN PLED DATA PROCESSING COPY