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STATE OF CALIFORW WATER RESOURCES CONT BOARD ' FORM `B': UN RGROUND STORAGE TANK PR GRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN ORMATION FOR EACH TANK. 2 10 MARK ONLY ❑ i NEW PERMIT F-] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 RMANENTLYCLO ONE ITEM E] 2 INTERIM PERMIT F—] 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE STANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: /'7l C717 FARM TANK-YES❑ NO (A) I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY (� A. OWNERS TANK ID# f9 3 1 R. MANUFACTURED BY: ak-- 00 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: so Q 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 PETROLEUM 8 C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 IL ❑ 1 ODUCT ❑ 4 GASAHCL ❑5 JET FUEL ❑fi AVIATION GAS ❑5 HAZARDOUS ❑ BO 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.M III. TANK CONSTRUCT19K MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ 1BLEW R) F-13 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM SI ALLED ❑4 SECONDARYCONTAINMENT ❑ 99 OTHER 1 STEEL71RON ❑ 2 STAINLESSSTEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/RBERGLAS$REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑S 100%METHANOL COMPAT18LEFRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PH LINING C. INTERIOR5 GLASS UNING 6 UNLINED UNKNOWN LINING ❑ ❑ ❑ IS UNING MATERIAL COMPATISLE WITH 10D%METHANOL? ❑YES NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT ❑ 3 LWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION E]5 CATHODIC PROTECTION ❑ 91 NONE 5 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IFUNDERGROU 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 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 E /IR A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U S 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 SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUALCHECK P S 2 INVENTORY RECONCILIATION A OSE WELLS P 6 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING 91 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 OUANTITY 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. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# =1 �] a o I a I N Lf EEO 13 CURRENT LOCAL AGENCY FACILITY ID p 4APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT ATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-9B) THIS FORM MUST BE ACCOMPANIED eY AFACILITY/SITE APPLICATION, FORM 'A',UNLESSU RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY