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STATE OF CALIFORNIA WATER RESOURCES CONTRf' BOARD FORM 'B': UND"GROUND STORAGE TANK PROURAM TANKTANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EIV-CHANGE OF INFORMATION ❑7 PERMANENTLY CLO ED TANK ONE ITEM 2INTERIM PERMIT ❑4 AMENDED PERMIT ❑81 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES 0 NO N 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY a) A. OWNERS TANK ID# B. MANUFACTURED BY: N YEAR INSTALLED D. TANK CAPACITY IN GALLONS' Q 11. TA CONTENTS IF(A1),IS MARKED,COMPLETE 1 M C.IF(A.1),IS NOT MARKED,COMPLET EM D. A M1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. 1 PRODUCT C ❑4 GASAHOL ❑5 JETUNLEADED 2 DUEL ❑6 AVIATION GAS ❑ ED 3 DIESEL 3 CHEMICAL PRODUCT ❑4 OIL ❑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 8 C.A.S.# C.A.S.#: III. TANK C 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 STEELPRON ❑2 STAINLESS STEEL ❑ 3FIBERGLASS 4STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑ MATERIAL 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 ION METHANOL COMPATIBLE FRP ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD UNING ❑ EPDXY LINING 4 PHENOLIC LINING LINING F-15 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN j ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES NO ❑W OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TARORASPHALT ❑3 VINYLWRAP 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 ,UF)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 95 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD 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 I VISUAL CHECK 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P S fi PRECISION TESTIN P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED IPTE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO ! � T FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. Ii APPLICANT' (PRI IGNAT pA7 a r X40 LOCAL AG C O Y CO R 9V �JURISDICTIfON# AGENCY# FACILITY IDS TANKIDM 1E= CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE♦WITH AREA CODE L- PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 4 3 �D CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: I� FORM B(5-29-BB) THIS FORM MUST BE ACCOMPANIEDWI A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILEDI DATA PROCESSING COPY