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STATE OF CALIFORN WATER RESOURCES CONTROARD FORM `B': UNDERGROUND STORAGE TANK PR RAM TAN TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH TIME FOLLOWING,j§F MATION FOR EACH TANK. C C� MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY GL05E0 TA ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED N FACILITY/SITE NAME WHERE TANK IS INSTALLED: t(/ FARM TANK-YES❑ NO tn I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY IV A. OWNERS TANK ID# 0 1 B. MANUFACTURED BY. C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: SOD II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. R 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM Ek C. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS 80 EMPTY 0 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF A HAZARDOUS SUBSTANCE STORED&C.A.S.# Iv C.A.S.J-A #: ✓.r III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑ 1 DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER El 95 UNKNOWN SYSTEM E212 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER �TEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 16 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 1 RUBBER LINED E] 2 ALKYD LINING El EPDXY LINING ❑ 4 PHENOLIC LINING LINING C. INTERIOR F-] 5 GLASS LINING 6 UNLINED ❑95 UNKNOWN 1:1 IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES [-] NO ®99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 5 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE AlIV 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A 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 U 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 U 6 CONCRETE A U 7 STEEL CLADW/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 1"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 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS PS PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 5 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1, ESTIMATE DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITYPF 3, WAS TANK FILLED WITH SUBSTANCE REMAI i G I GALLONS I E A TERIAL? ❑YES [:] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJU Y,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY EPERMITNUMBER JURISDICTION# AGENCY# FACILITY ID# TANK ID# [�E I I 1 —1 El I I ho I o I / I&- 1 0' Eol o lo El AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT AP RO AL ATE PERMIT XPIRATIONDATE 17 PERMIT AMOUNT SURCHARGE Allk FEE CODE RECEIPT# BY: FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY151TE APPLICATION, FORM `A`,UNLESS A v RRENT FORM`A' HAS BEEN FILED DATA PROCESSING COPY