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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION m COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. __re MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7'PERMANENTLY CLOSE NK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 9 8 TANK REMOVED oq FACILITY/SITE NAME WHERE TANK IS INSTALLED: '1j O S FARM TANK-YES❑ NO v 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# 0 D. MANUFACTURED BY: C. YEAR INSTALLED rD TANK CAPACITY IN GALLONS: 00 � I IL 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 B. C. ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL 3 HEMICAL PRODUCT �IL ❑ 1 PRODUCT ❑4 GASAHOL g 5�lEF FUEL ❑ 6 AVIATION GAS HAZARDOUS ❑ 90 EMPTY ❑ 95 UNKNOWN WASTE ❑ 7 METHANOL Lo 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAMEOF G '''� HAZARDOUS SUBSTANCE STORED 8 C.A.S.# C.AS.W O.] .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A. TYPE OF ❑ DOUBLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM V22 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER f STEEL/IRON ❑ 2 STAINLESS STEEL ❑3 F18ERGLASS ❑ 4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑81 OD%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR 1 RUBBER UNED ❑ ALMYOUNING F-13 EPDXY LINING ❑ 4 PHENOLIC UNING LINING ❑5 GLASS LINING 6 UNLINED ❑95 UNKNOWN IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES 0 N ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑9AR OR ASPHALT ❑ 3 VINYL WRAP ❑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 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U A STEEL71RON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A V 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. J' P 51 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P S 5 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE t. ESTIMATE TE LAST USED(MO/YR) 2. ESTIMAT UANTITY OF 3.WA T KF,ILLED WITH SUBST AINING IN iERIAL? []YES ❑ NO GALLONS THIS'FORk HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# TT CURRENT LOCAL AGENCY FACILITY ID# A OV f.B AME PHONE#WITH AREA CODE 7 D( L PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE I CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: FORM B(3-7-BB) THIS FORM MUST BE ACCO MPANI Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS,,.,ARENT FORMA' HAS BEEN FILED DATA PROCESSING COPY