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STATE OF CALIFORNs WATER RESOURCES CONTR*RAM OARD FORM 'B': UNDERGROUND STORAGE TANK PR ;mom TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 10 ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED cil FACILITY/SITE NAME WHERE TANK IS INSTALLED: s` FARM TANK-YES❑ NO N Cr) I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY —4 A. OWNERS TANK ID# I B. MANUFACTURED BY: 00 C.YEAR INSTALLED L D. TANK CAPACITY IN GALLONS: Q II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 232 LEADED ❑3 DIESEL 3 CHEMICAL PRODUCT ❑4 OIL �1 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 C.A.S.#: HAZARDOUS SUBSTANCE STORED&CA.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C.&D A.TYPE OF ❑ I DOUBUWALLM ❑3 SINGLE WAU.EDWITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM [;�2 SINGLEWAU-ED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER �1 STEELARON ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8108%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLICUNING C. LININ INTERIOR ❑ 5 GLASS LINING I 6 UNLINED ❑95 UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE fM 100%METHANOL? ❑YES ❑NO ❑99 OTHER rDCRORTROSION ❑ 1 POLYETHLENE WBAP ❑2 TAB OR ASPHALT ❑3 VIM'LWRAP 4 FIBERGLASS REINFORCED PLASTIC OECTION ❑ 5 CATHODIC PROTECTION1 NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABEGROUND. U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER U 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 5ALUMINUM A U 6CONCRETE A U 7STEELCLADW/FRP A U 9100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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 / VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P 8 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. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE l� LOCAL AGENCY USE ONLY pCHECK# JURISDICTION# AGENCY# FACILITY IDM TANK ID# L ENCY FACILITY ID# PHONE N WITH AREA CODE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE \ PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT M BY: �N FORM G(6-29-88) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A 'siRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY