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STATE,OF,�CALIFORNIA WATER RESOURCES CONTROL BOARD ' FORM 'B' "UNDERGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION ' TANK ., . COMPLETE A SEPARATE FORM WITH THE FOLLOWING ORMATION FOR EACH TANK 1 LC MARK ONLY ❑ 1 NEWPERMIT ' ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY 0 K ONE ITEM ❑2 INTERIM PERMIT ❑ 1 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: �i�'.11 FARMTANK-YES❑ NO IV I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A OWNERS TANK 10 M �-. B. MANUFACTURED BY: C.YEAR INSTALLED ✓f D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A1),19 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTORVEHICLE FUEL ❑ 2 ROLEUM B, C. ❑ I UNLEADED ❑2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL Pfl000CT 1 OIL DUCT ❑1 GASAHOL ❑ 5 J ❑6 AVIATIONGAS ❑5 HAZARDOUS ❑ 80 EMPTY [:D 95 UNKNOWN WASTE ❑7 METHANOL 99 OTHER(DESCRIBE IN REM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CAS.t 1 fQ ' CAS.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.AD A.TYPE OF ❑ 1 DWBLE WALLED ❑3 SINGLE WALED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM ❑2 SINGLEWALIID ❑ /SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESSSTEEL ❑ 3 FIBERGLASS 1 STEELCLADWIFIBERIGLSSSREINAMDRASTIC B.TANK MATERIAL, ❑ 5 WNCFETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 6 IWWUPHANOLCOWATIBLEFRP f ❑9 BRONZE _ a IB GALVANIZED STEEL ❑95 IWKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RJBBERUNED ❑2ALM LINING ❑ 3 EPDXY LINING ❑/PHENOLIC LINING LINING.- ;` -❑5 GLASS LINING ❑6 UNLINED 95 UNKNOWN '. IS LINING MATERIAL COIAPARBLE WYIH ion METHANOLI ❑YES [D ND ❑99 OTHER 0.CORROSION ❑ I POLYETHENE WRAP ❑2 TM OR ASPHALT ❑3 WNYLWNAP ❑M FIBERGLASS REIWORCFD 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 I 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 SINGLEWALLEO A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U " OTHER A U I STEELIIRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U I FISERGLASSPIPE A U 91 NONE C.MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEEL CLAD W/FRP A U 8100%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 7 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P t 3 VADOSE WELLS P 8 1 ELECTRONIC MONITOR P t 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 9 7 PRESSURE TESTING P t 91 NONE P S 95 UNKNOWN P t 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED OUANTITY OF3.WAS TANK FILLED WITH OALLONt _ SUBSTANCE REMAINING IN INERT MATERIAL? [:]YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO WLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED L SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY t '.JURISDICTION 9 AGENCY Y FACILITY ID P TANK ID t 3 ol EZ CURRENT LOCAL AGENCY FACIu'pj ID I APPROVED BY MAYE PHONE I WITH AREA CODE PERMIT NUMBER _ PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKI PEgYIT AMOUNT SURCHARGE AVT. FEE CODE ECEIPTI BY, Q� �' - �•�.' FORMB(6-29.88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLES SACURRENT FORMA' HASBEENFILED