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STATE OF CALIFORNII& WATER RESOURCES CONTROARD FORM B': UNDERGROUND STORAGE TANK PRO RAM TANKTANK PERMIT APPLICATION INFORMATION °< CO��'M..PPuuuL��ETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. :a MARK ONLY ❑PERMIT F-13 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED fo FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO 10 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# 8. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Q W II. TANK 2ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. N A. 1 MOTOR VEHICLE FUEL [72 PETROLEUM B. 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 ❑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&C.A.S.# All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF 1 DBUBILE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM V2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 71MINUM ❑ B 100%METHANOL COMPATIBLE RiP STE MATERIAL IL��,7/ ❑9 BRONZE ❑ 10 GALVANIZED EL 95 UNKNOWN ❑99 OTHER ❑ 1 RUBBERUNED ❑ 2 ALKYD LINING ❑3 EPDXY LINING ❑4 P LIC LINING C. INTERIOR F-15 GLASS UNING ❑6 UNLINED 95 UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 1011%METHANOL? ❑YES 0N 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TARORASPHALT ❑ 3 -WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION E] 5 CATHODIC PROTECTION E]91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE ArUl 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A 9 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 15 UNKNOWN A U 99 OTHER A U 1 STEEUIRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE 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 V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S S GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITV 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. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITYID# APPROVED N E „/ !- ' PHONE#WITH AREA CODE kpo PERMIT NUMBER 1„„•`^^'' PERMIT APPROVAL DATE (��I PE CH3R IT EXPIRAUTVION DAWTE ECKp PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORMB(3-7-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESSACURRENT FORMA' HASBEENFILED DATA PROCESSING COPY