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STATE OF CALIFORNI## WATER RESOURCES CONTROOARD FORM B': UNDERGROUND STORAGE TANK PRO RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. R MARK ONLY F-] 1 NEW PERMIT ❑ 3 RENEWAL PERMIT P"5CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK .� ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED CSi FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO ❑ I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY C) A. OWNERS TANK ID f B. MANUFACTURED BY: G YEARINSTALLED y, D. TANK CAPACITY IN GALLONS: 0 0 IL TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A3 CHEMICAL P OVEHICLE FUEL ❑ 2 PETROLEUM C ❑ I UNLEADED ❑ 2 LEADED IESEL LL1lCd PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 60 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,B D A TYPE OF ❑ 1 DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑2 SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRON 2 STAINLESS STEEL F-]3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK 715 CONCRETE 6 POLYVINYLCHLORIDE F-] 7 ALUMINUM E]B 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE 0 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER F-11 RUBBER LINED ❑ 2 A DLINING F__] 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING 5 GLASS LINING ❑ 6 UNLI ❑95 UNKNOWN � ❑ IS LINING MATERIAL COMPATIBLE WITH 100%M NOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2TAR OR ASPHAL ❑ 3VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND,14 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 / STEEL/IRON A U 2 STAINLESSSTEEL 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 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SEC 2DARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 5 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? [:jYES ❑ 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# Dul Ll 61 1= 6OG 171, CURRENT LOCAL AGENCY FACILITY ID APPROVED B PHONE N WITH AREA CODE V;lTlff oz PERMIT NUMBER U PERMIT APPROVAL DATE PE IT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: Allk FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORMA' HAS BEEN FILED