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STATE OF CALIFORNF ^ WATER RESOURCES CONTRf BOARD FORM 'B': UNDGROUND STORAGE TANK PR TANK RAM �- COMPLETE A g N pPERMM WITH THE FOLLOWING N INFORMATION FOR IEACH TANK. � a MARK ONS ONLYTEM ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT E] 5 CHANGE OF INFORMATION _.. o._ ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑7 PERMANENTLY CLOSED TANK ❑6 TEMPORARY TANK CLOSURENK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 'L. � G 1. TANK DESCRIPTIONFARM TANK-YES❑ NO COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY C. YEAR INSTALLEDD •O A. OWNERS TANK # —2,- B. MANUFACTURED BY D. TANK CAPACITY IN GALLONS: 0 IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. FNOT R VEHICLE FUEL ❑ 2 PETROLEUM B C ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL CAL PRODUCT ❑4 OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS DOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 ME HANDL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) R VEHICLE FUEL,ENTER NAME OF SUBSTANCE STORED&C A.S.# C.A.S.It. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,6 D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE W7 ALLED ❑4 SECONDARYGONTAINMENT ❑99 OTHER B.TANK ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBEGLASSPEINFORCED PLASTIC MATERIAL ❑ 5 CONCREFE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED ❑95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL 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 U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 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 U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/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 U 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 S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P 8 95 UNKNOWN P S 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? ElYES [:] 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3q I = z CURRENT LOCAL AGENCY FACIL ID# APPROVED BY NAME PHONE#WITH AREA CODE 1 //Y 7/ /C— PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 2 /V CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE �ENTFORMW BY: FORM B(6-29-M) THIS FORM MUST BE ACCOMPANIED A FACILITY/SRE APPLICATION, FORM 'A',UNLESS HAS BEEN FILED `�--- DATA PROCESSING COPY