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STATE OF CALIFORNIV WATER RESOURCES CONTROI -:)ARD FORM 'B': UNDEk taROUND STORAGE TANK PROOrr:AM TANK TANK PERMIT APPLICATION INFORMATION , COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT F-]4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ZE2_8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: I C FARM TANK-YES❑ NO •Q I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.3),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑4 OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 00 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 CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.&D A.TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER F-1i SUEUIRON ❑2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ MATERIAL 5 WNCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 100%METHANOL OOMPATIBLEFRP ❑9 BRONZE ❑10 GALVANIZEDSTEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RIBBER LINED ❑2 ALKYDUNING ❑ 3 EPDXY LINING ©A PHENOUCUNING LINING ❑5 GLASS LINING ❑6 UNLINED ❑ 95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH In METHANOL? F]YES L[n-NO D9 OTHER D.CORROSION ❑ 1 POLYETHLFNEWRAP ❑2 TAR 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 91 NONE A U 95 UNKNOWN A U 99 OTHER S. 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 STEELASON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEELCLADW/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 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P B I PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E]YES [jNO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# ml i F-TTF ( / CURRENT LOCAL AG{{EIINCY FACILRY IO# APPROVED BY NAME PHONE#WITH AREA CODE C/�. PIERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ` lz4llqu CHECK PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-68) THIS FORM MUST BE ACCOMPANIE$EY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CUARENT FORMA' HAS BEEN FILED DATA PROCESSING COPY