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STATE OF CALIFORNIib WATER RESOURCESCONTROARD FORM 'B': UNDE GROUND STORAGE TANK PRO RAM ' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSEDT K ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑6 TEMPOR'A'RY TANK CLOSURE [:]8 TANK REMOVED 191 FACILITY/SITE NAME WHERE TANK IS INSTALLED #.p W TLPO FARM TANK-YES❑ NO ET z I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SP CIFY IC A. OWNERS TANK ID# B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D I i A 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM R. C. El 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 �Ip HAZARDOUS SUBSTANCE STORED&C A.S.N ' t C.A.S.#: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,S D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH DRERIOR LINER ❑95 UNKNOWN SYSTEM C 2 SINGLE WALLED ❑4 SECONDARYCONTAINMENT ❑99 OTHER 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR F-11 RUBBER LINE ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOUC LINING LINING ❑ 5 GLASS LINING Lal UNLINED ❑95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 10D%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION Ji 9 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A 01 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U S ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%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 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S I PRESSURETESTING ffl S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST V /�1 U ED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH J X [� SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E]YES 10 i 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# 3 �lI DD I / ? Da 1 o CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY N I AT Z_� g ,P HONE#WITH AREA CODE PERMIT NUMBER 9'6PERMIT APPROVAL DATE PERMIT EXPIRATION DATE `(f\r CNECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTk BY: \V,e\11_I LLJ FORM 8(3-7-BB) THIS FORM MUST BE ACCOMPANIMY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY