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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM ' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 10 ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: gazraarma FARM TANK-YES❑ NO N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID k h, B. MANUFACTURED BY: r (,n C. YEAR INSTALLED a,k D. TANK CAPACITY IN GALLONS: &A4 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A7),IS NOT MARKED,COMPLETE ITEM D. A. ❑ i MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY Ee 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.R C.A.S.t: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ 1 DOUBLE WALLID ❑3 SINGLE WALLED MTH EXTERIOR LINEA95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER F-11 STEDURON ❑ 2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE [:] 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP �� r�/ ❑9 BRONZE ❑ 10 GALVANIZED STEEL SIA' "�UNKNOWN ❑99 OTHER C. INTERIOR ❑I RWBERUNED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑ PHENOLIC UNING LINING F-15 GLASS LINING ❑6 UNUNED V995 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 10D%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑i POLYETHLENE WRAP ❑2 TARORASPHALT ❑ NYLWAAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER 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 NONE 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 NONEC A U.A UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED ST L A 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 8 1 VISUALCHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P -4-ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE CP S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATEDOUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING INWLLONB 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION t AGENCY W LIFYi TANK ID t 3 CURRENT L CY FA APPROVED BY NAME PHONE t WITH AREA CODE PERMITHUMB PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKt PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT FORM B(6-29&88) THIS FORM NIST BE ACCOIWANIE BYAFACILITY/SITE APPLICATION, FORM 'A',UNLESS A ,JRRENT FORMA HAS BEEN FILED DATA PROCESSING COPY