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STATE OF CALIFORN WATER RESOURCES CONTROARD FORM `B': UNDE GROUND STORAGE TANK PRMRAM y„ TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION •`o 10 ONE ITEM 2 INTERIM PERMIT ❑ 7 PERMANENTLY CLOSED TANK ❑4 AMENDED PERMIT ❑B TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: I Q FARM TANK-YES❑ NO '❑ ,p I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY CO A. OWNERS TANK ID# B. MANUFACTURED BY: N C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: -U II. TANK C94TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. ❑ 1 UNLEADED LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT E] B.4 OIL RODUCT ❑4 GASAHOL ❑ 5 JET FUEL 6 AVIATION GAS 5 HAZARDOUS 0 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 8 C.A.S.# N CA S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D [A. YPE OF ❑ ' DOU WAS ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN YSTEM SI WALLED4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC ANK 5 CONCRETEATERIAL ED ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER . INTERIOR 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED 95 UNKNOWN E]IS LINING MATERIAL COMPATIBLE WITH 10D%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENEWMP ❑ OR ASPHALT ❑3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMARON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 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 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CH 7n A U 4 FI RGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A CONCRETE A U 7 STEEL CLAD VY A U 9 GALVANIZED STEEL U A U 8 100%METHANOL COMPATIBLE FRP UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR ECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK 8 21NVENTORV RECONCILIATION P 8 3VA�WE�ELSP 8 4ELECTRONIC MONITOR P 8 5Gg0UND WATER MONITORINGR 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NP S 96 UNKNOWN P 6 89 OTHER On INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DAT T U D(MO/YR) 2. ESTIMATED OUANTITV OF SUBSTANCE REMAINING IN 3. WAR TANK FILLED WITH OALLONe INERT MATERIAL? ❑yES [] NO THIS FORM AS 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 C0� JURISDICTION�m AGENCY# � FACILITY ID# TANK ID N CURRENT LOCAL ADENYFACILI IqN� a / APPROVED By A NONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERM EKPIRATIO 7 ATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# Aft BY: FORM a(6-2e-ee) THIS FORM MUST BE ACCOMPANIED A FACILITY/SITE APPLICAT , FORM `A',UNLESS A U , ENT FORMA' HAS BEEN FILED DATA PROCESSING COPY