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STATE OF CALIFORNIA* WATER RESOURCES CONTRO.OARD FORM B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLO I ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLO/nS�UR,AE/ ❑8 TANK REMOVED N FACILITY/SITE NAME WHERE TANK IS INSTALLED: 0 I /� FARM TANK-YES❑ NO C�'I I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY W A. OWNERS TANK ID# B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: OD II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. / A. Ell MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT ❑ 4 OIL F riPRODUCT ❑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 ON Y IN BOX A,B.C,&D A TYPE OF ❑ I 'GLLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINEWALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 2 I-STEEUIRON ❑2 STAINLESS STEEL ❑3 RBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 6100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RIBBER UNED n 2ILKYD LINING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING Z6 UNLINED ❑95 NKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLEWITH 1W%METHANOL? ❑YES ❑NO 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FlBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 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 U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 5 UNKNOWN A U 99 OTHER B.CONSTRUCTION WOUD 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 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUMCONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U 95 UNKNOWN A A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. / P 1 VISUAL CHECK 2 NVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS SSS P S PRECISION TESTING S 7 PRESSURE TE STING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED�/I/DATE ST USED(MI 2.ESTIMATED OU ITY OF 3.WAS TAN FILLED WITH / SUBSTAN ING IN GALLONS IN T IAL? E]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 LOCAL AGENCY USE ONLY COUNTY* JURISDICTION# AGENCY# FACILITY ID# TANK ID# 1 ,016 led � CURREN OC AOE CY FACI ITY ID#� APPROV Y NAME ONE#WITH AREA CODE PERMIT NUMBER NNUUMBER Z PERMIT APPROVALOATE PER MI %PIRATION DATE CHECK# PArl ERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(5-29-ee) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY