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STATE OF CALIFORNI WATER RESOURCES CONTR' BOARD FORM `B': UNDERGROUND STORAGE TANK PRdGRAM ^ TANK TANK PERMIT APPLICATION INFORMATION ° COMPLETE A SEPARATE FORM WITH THE FOLLOWING 1 ORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 19<GHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 10 ONE ITEM F-12 INTERIM PERMIT F-] 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED 'j FACILITY/SITE NAME WHERE TANK IS INSTALLED: a/-7FARM TANK-YES❑ NO cil I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CID --J A. OWNERS TANK ID N B. MANUFACTURED BY: C. YEAR INSTALLED O D. TANK CAPACITY IN GALLONS oaq II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. [B'I'MOTOR VEHICLE 2 LEADED F.�r3 DIESEL A ❑3 CHEMICAL PROD CTL 4 OOETROLEUM IT7F, PRODUCT C ❑4 GASAHOLD ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN L❑J2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.P C.A.S.#: III, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A.TYPE OF ❑ 1 DO LEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM SINGLE WAILED ❑4 SECONDARY CONTAINMENT ❑99 OTHER L/IRON ❑2 STAINLESS BTEEL ❑ 3 RBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK F7 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNED ❑2 A DUNING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR LINING ❑5 GLASS UNING LiXUNUNED ❑95 OKNOWN ❑ ISUNING MATERIAL COMPATIBLENTH 100%METHANOL? E]YES ❑NO FZKOTHER � D. CORROSION ❑ 1 POLYETHLENE WRAP TAR OR ASPHALT ❑3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASDC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A 0 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 U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 5 UNKNOWN A U 99 OTHER A U 1 STEELARON 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 U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A095 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 G P S 1 VISUAL CHECK 00 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS �l J P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 6 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED IMO/VR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO GALLONS 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 k AGENCY R FACILITY ID N TANK ID N CURRENT LOCAL AGENCY FACILRY ID APPROVED BY NAME PHONE#WITH AREA CODE SERB G a PERMIT NUMBER PERMIT APPROVAL DATE PE IT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: FORM B I6 29 RBI THIS FORM MUST BE ACCOMPANIED-BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A GGIARENT FORMA HAS BEEN FILED / DATA PROCESSING COPY