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STATE OF CALIFORNIf WATER RESOURCES CONTROP YARD FORM 'B': UNDEftROUND STORAGE TANK PRO afiAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TAN ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE . W FACILITY/SITE NAME WHERE TANK IS INSTALLED: (ll.� FARM TANK-YES❑ NO (,V 1. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY IV A. OWNERS TANK ID X 3 1 B. MANUFACTURED BY'. C. YEAR INSTALLED 4` D. TANK CAPACITY IN GALLONS: /000 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ® 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. E:] 1 UNLEADED ®2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT [:] 4 OIL ® 1 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 HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ I 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 WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER F-] 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING F__] 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ ((TT 95 UNLINED LAU 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWMP ❑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 AU 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 STAINLESSSTEEL 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 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 095 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. PRPS 1VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P S 4ELECTRON IC MONITOR P S SGROUND WATER MONITORING WELLS ,v P S 6 PRECIS ION TESTING P S 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 QUANTITY 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, APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY M FACILITY ID N TANK ID N EF] I o 10 1 l 14 1 & I I 1 as a3 CURRENT LOCAL AGENCY FACILITY ID knVED NA PHONE N WITH AREA CODE C PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 7 �l� CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT* BY: `\V FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A URRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY