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STATE OF CALIFORN WATER RESOURCES CONTROARD r?E' : FORM `B': UNDERGROUND STORAGE TANK PROGRAM T TANK PERMIT APPLICATION INFORMATION ` } " TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. L MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO D i ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED /6 FACILITY/SITE NAME WHERE TANK IS INSTALLED: `l. FARM TANK-YES❑ NO coN I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: CD C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. EJIIIMOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C' E] 1 UNLEADED ❑ 2 LEADED F-] 3 DIESEL 3 CHEMICAL PRODUCT F-] 4 OIL �IPRODUCT ❑ 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.#: III. TANK CONSTRUCTION MARK ON ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 INGLE WALLED WITH EXTERIOR LINER E]95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED F-]4 S ONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAT ESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVI L CHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FAP MATERIAL ❑ 9 BRONZE ❑ 10 GALVAN ED STEEL ❑ 95 UNKNOWN ❑99 OTHER C.INTERIOR F-] 1 RUBBER LINED El ALKYD LININ ❑ 3 EPDXY LINING F-]4 PHENOLIC LINING LINING F-] 5 GLASS LINING F-]6 UNLINED F-]95 UNKNOWN [:] IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL. ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION [-] 5 CATHODIC PROTECTION E]91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U F UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 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 STAINLESS STEELU 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE U 7 STEEL CLADW/FRP 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 S ONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLAC 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY EPERMITUWBER JURISDICTION# AGENCY# FACILITY ID# TANK ID# 1 Ll 1 1 161011161 � 7 AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE S in PERMIT APPROVAL DAT PERMIT EXPIRATION DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANI A FACILITY/SITE APPLICATION, FORM RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY