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STATE OF CALIFORNU& WATER RESOURCES CONTRRD gEp.wo::y,s FO RM `B': UNDEMROUND STORAGE TANK PROQWM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. `"'.a^"'` z 30 MARK ONLYj2-'INTERIM PERMIT F13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C ONE ITEM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVE i/ w FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO N co I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CTI A. OWNERS TANK ID# IJ.s 1 B. MANUFACTURED BY: y C. YEAR INSTALLED 414,1 1 D. TANK CAPACITY IN GALLONS: I !f II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D., A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C ❑ I UNLEADED 2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT [:] 4 OIL Z 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 HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM rf-2'-SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 1N%METHANCLCOMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR El1 RUBBER LINED ®2 ALKYD LINING F-13 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING 2-6 UNLINED ❑95 UNKNOWN J, ® I$LINING MATERIAL COMPATIBLE WITH 100%MEFHANOL7 ❑YES ❑ NO � OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TAP OR ASPHALT 3VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:] 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A CY2PRESSURE 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 A U 1 STEELI 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 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER J LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER /VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED ATE LAST USED(MO/YR) 2. ESTI ATED OUANTITY OF 3.WAS T r K FILLED WITH S B T NCE REMAINING IN GALLONS ,�.y I /�TERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENAL OF PERJURY,AND TO THE BEST OF MY KNOWL C7GE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY r COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# � ok � s RRENT LOCAL AGENCY.FACILITY ID# APPROVED BY NjyAE PHONE#WITH AREA CODE l -- I l t _ PERMIT NUMBER PERMIT APPRO AL TE PERMIT EXPIRATION DATE CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE �RECEIPT k BY: 1 FORM B(6-29-as) THIS FORM MUST BE ACCOMPANIED Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY