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STATE OF CALIFORNV' WATER RESOURCES CONTRO' 'OARD FORM 'B': UNDERGROUND STORAGE TANK PRO aMAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z o_ MARK ONLY F-11 NEW PERMIT F-] 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION F-] 7 PERMANENTLY CLOSED TANK 10 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED ^4 Ca FACILITY/SITE NAME WHERE TANK IS INSTALLED: ;,f FARM TANK-YES❑ NO N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY W OD A. OWNERS TANK ID# B. MANUFACTURED BY: OD C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: L.yo II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,p6mPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB C. 1 UNLEADED ❑ 2 LEADED E:] 3 DIESEL 3 CHEMICAL PRODUCT E] 4 OIL 1 PRODUCT Lj 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 ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 LUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL V95 UNKNOWN ❑99 OTHER C. INTERIOR F-] 1 RUBBER LINED El2ALKYO LINING ❑ 3 EPDXY LINING n AHENOLIC LINING LINING ❑5 GLASS LINING ❑ amu(6 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLEWITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP F-14 FIBERGLASS REINFORCED PLASTIC PROTECTION E] 5 CATHODIC PROTECTION El91 NONE L-!E� "5 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 05 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 4kA5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STANLESSSTEEL A U 3 POLYVINYL CHLORIDE PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U §CONCRETE A U 7 STEEL CLAD VI A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE 5 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES E] 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 10# ® In a 11 1012- 1d (n CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NU ER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE ANT. FEE CODE RECEIPT# BY: FORM B cs-zs-BBl THIS FORM MUST BE ACCOMPANIED FACILYIY/SYfE APPLICATION, FORM 'A',UNLESS A C ENi FORMA' HASSEENFILED DATA PROCESSING COPY