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STATE OF CALIFSINIA WATER RESOURCES&TROL BOARD .� FORM 'B': UNDERGROUND STORAGE TANK PROGRAM , TANK :,.- TANK PERMIT APPLICATION INFORMATION t.: COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION El 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED �p FACILITY/SITE NAME WHERE TANK IS INSTALLED: gI /.� FARM TANK-YES❑ NO I I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID N r GB. MANUFACTURED BY: C. YEAR INSTALLED Lf D. TANK CAPACITY IN GALLONS: Coo 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 P ROLEUM B. C. ❑ I UNLEADED ❑2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT � 4 OIL ❑ I PRO UCT [D4 GASAHOL ❑5 JET FUEL El AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY [:]95 UNKNOWN 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.N C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.S,C,A D A.TYPE OF ❑ I DOUBLE WEED ❑3 SINGLE WALLED WITH EXTERIOR LINER SYSTEM © El 95 UNKNOWN SINGLE WALLED ❑/SECONDARY CONTAINMENT ❑ 99 OTHER Q"TANK 1 STEEUIRON ❑2 STAINLESS STEEL E] 3 FIBERGLASS ❑ 1 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.MATERIAL ❑5 CONCRETE ❑8 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑6 IW%METHANOL COMPATIBLE FRP ED 9 BRONZE 0 10 GALVANIZED STEEL [D.95 UNKNOWN E] 99 OTHER C. INTERIOR ❑ 1 FUBDERLINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ 1 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED ❑UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP E] 1 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITYA A U 91 NONE A U UNKNOW U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U UNKNOWN U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 8 CONCRETE A U I STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U5 UNKNO N 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 • 1 VISUAL CHECK P • 2 INVENTORY RECONCILIATION P • 3 VADOSE WELLS P • 1 ELECTRONIC MONITOR P • 5 GROUND WATER MONITORING WELLS P • 8 PRECISION TESTING P • 7 PRESSURE TESTING P • 91 NONE P • 96-umu-46-wir P • 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE F71. EEST715MATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANT11Y OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? 1:1 YES NO GALLON• THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO WLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N Eo L I CURRENT LOCAL AOE/NCr fACILITII ID/ APPROVED BY NAME PHONE 0 WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK I PERMIT AMOUNT •URCHARGE AMT. FEE CODE RECEIPT/ BY: Cc - 7� I ORM B(8-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION. FORM 'A',UIII EBR A ri E,axwe