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STATE OF CALIFORNO WATER RESOURCES CONTROARD FORM `B': UNDERGROUND STORAGE TANK. PROGRAM TANK TANK PERMIT APPLICATION INFORMATION - COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFO MATION FOR EACH TANK. o. ' MARK ONLY E 1 NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM 0 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED r/r FACILITY/SITE NAME WHERE TANK IS INSTALLED: �` ,n� FARM TANK-YES NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: l ` C. YEAR INSTALLED G D. TANK CAPACITY IN GALLONS: 0 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. H► A. MOTOR VEHICLE FUEL F-] 2 PETROLEUM B. C, 1 UNLEADED LEADED 3 DIESEL to 3 CHEMICAL PRODUCT E] 4 OIL PRODUCT ❑ 4 GASAHOL 5 JET FUEL 6 AVIATION GAS 5 HAZARDOUS ❑ BO EMPTY ❑ 95 UNKNOWN 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF I HAZARDOUS SUBSTANCE STORED&C.A.S # / C.A.S.M: fff/ x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BO A,B,C,&D A. TYPE OF L l 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 5 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED E] 4 SECONDARY CONTAINMENT El 99 OTHER 1 STEEL/IRON r-] 2 STAINLESS STEEL F-] 3 FIBERGLASS 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE 0 6 POLYVINYL CHLO910E [:]H�5 L UM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL El 9 BRONZE � 10 GALVANIZED STEEL UNKNOWN 99 OTHER I RUBBER LINED 2 ALKYD LINING ❑3 EPDXY LINING El 4 P LIC LINING G. INTERIOR LINING El 5 GLASS LINING F-] 6 UNLINED 95 UNKNOWN 0 IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑ NO ❑ 99 OTHER D. CORROSION I POLYETHLENE WRAP 2 TAR OR ASPHALT V95UMKNOWN WRAP El FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION E] 91 NONE Ll 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE a SYSTEM TYPE A U 1 SUCTION 2 PRESSURE A U 3 GRAVITY A U 99 OTHER L- L),)/" B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH U 5 UNKNOWN A U 99 OTHER A U 1 STEFLfIRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEELU 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 S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS S' 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P 5 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1, ESTIMATED DATE LAST USE[)((Mg/YR) _ 2- ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? �YESE�N() GALLONS THIS FORM HAS BEEN bOMPLETED 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 ID# = I I 1 -1 1 1 1 1 1 H/ LK-L21 I c-)I o F2 CURRENT LOCrENCY AGILITY ID# APPROVED BY NAME, PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE RM IT EXPIR N DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: look f FORM B(3a-8a) THIS FORM MUST BE ACCOMPANIEIWA FACILITY/SITE APPLICATION, FORM `A',UNLESS A tau RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY