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STATE OF CALIFORNO WATER RESOURCES CONTROARD FORM `B': UNDERGROUND STORAGE TANK PROGRAMa TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. e MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT HANGE OF INFORMATION El 7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE E]8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED:&,:/)?o FARM TANK-YES❑ NO .�► I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY L•a A. OWNERS TANK ID# B. MANUFACTURED BY: 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 O. A. ❑ 1 TOR VEHICLE FUEL F-1 2 PETROLEUM B. C• 1 UNLEADED 2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT F 4 OIL 1 PRODUCT 4 GASAHOL �ET L 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN 2 WASTE 7 METHANOL (DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: rr� III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXA,B,C,8 A.TYPE OF ❑ i DOUBLE WALLED F-]3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM 2 SINGLEW LLED 4 SECONDARY CONTAINMENT 99 OTHER STEEL/IRON 2 STAINLESS STEEL F 3 FIBERGLASS E]4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK F-1 5 CONCRETE 6 POLYVINYLCHLORIDE F-] 7 ALUMINUM [:j 8 100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE E] 10 GALVANIZED STEEL [::]95 UNKNOWN E]99 OTHER i 1 RUBBER LINED 2 ALKYD LINING F-] 3 EPDXY LINING 4 PHEN LINING C. INTERIOR LINING ❑ 5 GLASS 6 UNLINED UNKNOWN v� ' / IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES NO OTHER K D.CORROSION ❑ 1 POLYETHLENE WRAP F-1 2 TAR OR ASPHALT 3 WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN E] 99 OTHER i 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 91 NONEU' 5 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 U' 5 UNKNOWN A U 99 OTHER A U 1 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- 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 9 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 P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER I. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USEDMO/YR) 2. ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E]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 Jqk" COUrnNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# I E[ I LLI / 1713 [- :J7 I If_ CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME P ONE#WITH AREA CODE *(� 4 � PERMIT NUMBER PERMIT APPROVAL DATE PEFOITE PIRATION DAT CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: 3 0 29-88) THIS FORM MUST BE ACCOMPANkIM FACILITY/SITE APPLICATION, FORM `A',UNLESS AWRENT FORMA' HAS BEEN FILED 5(I Y t DATA PROCESSING COPY