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STATE OF CALIFORNI WATER RESOURCES CONTRf- BOARD FORM `B': UNDERGROUND STORAGE TANK PRI GRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1 NEW PERMITI C E:]3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: W ' FARMTANK-YES❑ NO C) I. TANK DESCRIPTION C PLETE ALL ITEMS-IF UNKNOWN-SOS Y 00 A. OWNERS TANK ID# B. MANUFACTURED BY: � C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: S-06 - 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 ROLEUM B. C. ❑ 1 UNLEADED V29LOTDED ❑3 DIESEL ❑3 CHEMICAL PRODUCT 4 OIL ❑ 1 ODUCT ❑4 GASAHOL FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN 2 WASTE ❑7 METHANOLHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAMEOF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ i BLE WALLED 03 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGUSS REINFORCED PLASTIC B'TANEHUL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑10 GALVANIZEDSMIL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑3,0YD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS UNING Er6 UNLINED ❑95 UNKNOWN' , / ❑ IS UNING MATERIAL COMPATISLE WITH 100%METHANOL? ❑YES ❑ NO [L�90THEq/�'/v D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VI WRAP `❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UND OUNO,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION U 1 SINGLE WALLED A U 2 DOUBLE WALLED A 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEELGLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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. Y-1 v S 1 VISUAL CHECK 8 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTI D QUANTITY OF 3. WA TANK FILLED WITH 8 B N REMAINING IN GALLONS ATERIAL? ❑YES ❑ NO THIS FORM HAS EN COMPLETED UNDER PENAL7k OF PERJURY,AND TO THE BEST OF MY KN LEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# FD-F7-1l 3 2-1 1 U 10 1 c Rl CURRENT LOCAL AGENCY FACILITY ID# APPR VED BY NA E PHONE#WITH AREA CODE 7_7 PERMIT UMBER PERMIT APPA VAL D TE PERMIT EX IRAT ON DATE CHECK N PEIT AMOUNT SURCHARGEMT. FEE CODE RMRECEIPT# BC �J/FORMB(6-29-m) THIS FORM MUST BE ACCOMPANIEDAFACILITY/SITE APPLICATION, FORM 'A',UNLESS At4RRENT FORMA' HASBEENFILED