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STATE OF CALIFORNIA WATER RESOURCES CONTRO OARD ° FORM 'B': UNDERGROUND STORAGE TANK PROI AM TANK TANK PERMIT APPLICATION INFORMATION q ro µ3 COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ z MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ,i CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED !/ FACILITY/SITE NAME WHERE TANK IS INSTALLED: , r FARM TANK-YES NO ❑ (,n I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 1-� A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CO. TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL F--] 3 CHEMICAL PRODUCT ❑ 4 OIL ElPRODUCT ❑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.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A.TYPE OF ❑ 1 UBLEWALLED F-13 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM KI 2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 SMEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B in METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR F-11 RUBBER LINED E:]2 NING F-13 EPDXYUNING ❑4 PHENOLIC LINING LINING ❑5 GLASS UNING DD16UNILINED ❑95 UNKNOWII/yy,�'-�/ ❑ IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? ❑YES ❑ NO OTHER �"'^' - D.CORROSION n YOILYETHLEME WRAP ❑2 TARORASPHALT 'WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION uP/5 CATHODIC PROTECTION ❑91 NONE M5 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMAT CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IFAPPLICABLE A.SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE 5 UNKNOWN A U 99 OTHER B.CONSTRUCTION A ml SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A D'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 ALUMINUM A&CONCRETE A U 7 STEEL CLAD W/FRP A U B 190%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUALCHECK P 5 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS _ P 6 PRECISION TESTING 8 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 DA E LAST USED(MO/YR) 2. ESTIM TED QUANTITY OF GALLONS 3.WAS TANK F L WITH SUB ACE REMAINING IN INERT ? [:]YES ❑ NO THIS FO HAS BEEN COMPLETED UNDER PENAL OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT AGENCY FAY FA ILI� AP D NAMC PHONE M WI0AREAOCODE ,USEZ t l2. P MI NUMBER PERMIT APPROVAL DATE PER IT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-66) THIS FORM MUST BE ACCOMPA BY A FACILITY/SITE APPLICATION, FORM 'A',UNLES CURRENT FORM'A' HAS BEEN FILED