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STATE OF CALIFORN, WATER RESOURCES CONTR(__ BOARD FORM 'B': UNDERGROUND STORAGE TANK PRWRAM TANK TANK PERMIT APPLICATION INFORMATION ,mom COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. . ' MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 0215"CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED / FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 10 A. OWNERS TANK ID# B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: W H. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. '1MOTOR VEHICLE FUEL ❑2 PETROLEUMB. C. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL N F-13 CHEMICAL PRODUCT ❑ 4 OIL 1 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&CA.S.k 404 CA.S.k: x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1D�UBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER E]95 UNKNOWN SYSTEM ❑'�SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER l STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC I. B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 i00%mETHANOLCOMPAnBLEFRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ C.INTERIOR 1 RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXY LINING ❑4 PH C UNING LINING ❑5 GLASS LINING ❑6 UNUNED UNKNOWN ❑IS LINING MATERIAL COMPA11MI NTH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETFILENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 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& / 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 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 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 5 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 RECCILIATION P 3 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESS URE T9/ NONE' P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES [::] NO NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N� JURISDICTION N AGENCY 8 FACILITY ID# TANK ID M IJU---�-� Ll 0 161 ()1113161Z] bO CURRENT LO AGENCY FACILITY 10 X APPROVED BY NAME PHONE 8 WITH AREA CODE a PERMIT NU ER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK i PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT M BY: FORM B(3-7-88) THIS FORM RUST BE ACCOMPA BY I FACILITY/SITE APPLICATION, FORM 'A',UNLE URRENT FORU'R HAS BEEN FILED 0ATA PROCESSING COPY ? \