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STATE OF CALIFORN WATER RESOURCES CONTR�OARD FORM `B': UND GROUND STORAGE TANK PROGRAM a. o> A '; TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. .� MARK ONLY 011 NEW PERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED 0t FACILITY/SITE NAME WHERE TANK IS INSTALLED: c FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY Ip A. OWNERS TANK ID# 4e- B ' . MANUFACTURED BY: C. YEAR INSTALLED 6---e I D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(&I),IS NOT MARKED,C MPLETE ITEM D. CAl GJ A. ❑1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ q OILA 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.#: zlll. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH E7TERIOR UNER ®95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL [:]3 FIBERGLASS ❑4 STEEL CND W/RBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE E]MATERIAL6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 100%MEfHANOLCOMPATIBLE FFlP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ®95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR I RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXYUNING 4 PHENOUCUNING ❑ LINING ❑5 GLASS UNING ❑6 UNLINED ®95 UNKNOWN ❑ISUNING MATERIAL COMPATIBLE WITH 100%MMMOL9 ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL NRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 5d 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C.MATERIAL A U 5 ALUMINUM A U S CONCRETE A U 7 STEEL CLAD WEEP 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 1 VISUAL CHECK OF S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 'H P 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LA ST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAST MATERIAL?ILLED WITH N SUBSTANCE REMAINING IN NERT MATERIAL? ❑YES ❑ NO GALLONB THIS FORM HAS BEEN COMPLETED 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 COUNI® JURISDICTION � AGENCY# FACILITY ID# O TANK ID# Q O 7 M CURRENT LOCAL AGENCY FACILITY ID# APPR VED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPRO^OVVAL DAT PERMIT EXPIRATION DATE U — S CHECKM PERMITAMOUNT SURCHAR EAMT FEE CODE RECEIPT BY: J FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED BYA FACILITY/SRE.APPLICATION, FORM`A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY