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STATE OF CALIFORNIA WATER RESOURCESCONTRC' SOARD :.:: '• FORM B': UNDERGROUND STORAGE TANK PR6 RAM =� ` TANK TANK PERMIT APPLICATION INFORMATION m ti COMPLETE A SEPARATE FORM WITH THE FOLLOWI INFORMATION FOR EACH TANK. MARK ONLY 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLYCL DTANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6;TEMPORARY TANK CLOSURE ❑B TANK REMOVED I FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY a) A. OWNERS TANK ID# B. MANUFACTURED BY:cz& W C. YEAR INSTALLED D. TANK CA CIN IN GALLONS: II. NK CONTENTS IF(A.1),IS MARKED,COMPLETE IT C.IF(A.1),IS NOT MAR ED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUMB. C. 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL 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&C.A.S.# C.A.S.#: III. TANK CO STRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A.TYPE OF 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3FIBERGLASS Nb 4STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑B 10V%METHANOLCOMPATIBLEFRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RUBBER UNED 2 ALKYDUNING ❑3 X(YUNING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING 6 UNUNED ❑ 95 UNKNOWN, 1 E] IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? E]YES NO 99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TARORASPHALT ❑3 VINYL WRAP N14 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 U1 SUCTION U 2 PRESSURE A U 3 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 U 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 uFIBERGLASS PIPE A U 91 NONE 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 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 VISUAL CHECK $ 2 INVENTORY RECONCILIATION P $ 3 VADOSE WELLS P B 4 ELECTRONIC MONITOR P $ 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING 7 PRESSURE TESTING P S 91 NONE P 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED Or LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH A/ SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? [-]YES ❑ NO To FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. !, APPLICANT'S M P TEDBSIG E) DATE LOCALAqtNq C NTY JURISDICTION# AGENCY# FACILITY ID# TANK ID# 1,'3 = I I I 03 CURRENT C�LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE � PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE III CHECK N 7iRMR AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: L-� THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY