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STATE OF CALIFORNN WATER RESOURCES CONTR_--BOARD Qp FORM 'B': UNDERGROUND STORAGE TANK PROGRAMANK TANK PERMIT APPLICATION INFORMATIONCOMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z MARK ONLY ❑ ❑ ❑ 5 CHANGE OF INFORMATION ❑ 7 P RMANENTLY CLOSED nTANK I O 1 NEW PERMIT 3 RENEWAL PERMIT �T ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE B TANK REMOVED 1 Ll I W FACILITY/SITE NAME WHERE TANK IS INSTALLED: OD 4V. FARM TANK-VES NO u N I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CAD A. OWNERS TANK ID a G B. MANUFACTURED BY: W C. YEAR INSTALLED (�1nn,{�(/ D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A El'IMOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL ❑ 3 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 S C.A.S.a C.A.S.a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,a D A. TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ t STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIALE:] 9 BRONZE ❑ 10 GALVANIZED STEEL d95 UNKNOWN ❑ 99 OTHER C.INTERIOR1 RUBBER LINED [-] 2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING ' LINING ❑ 5 GLASS LINING ❑6 UNLINED r2(.5 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IOD%METHANOL? ❑YES ❑ NO 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑27Ap 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 IFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 5 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 9/ NONE AlU 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3-POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEEL GLAD W/FRP A U 8100%METHANOL COMPATIBLE ERP A U 9 GALVANIZED STEEL A 0 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. N0 1 P 5 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 W P 5 6 PRECISION TESTING P S 7 PRESSURE TESTING P 1 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIM TED DATE LAST USED(MO/YR) 2. ESTIMATE QUANTITY OF 3.WA TANK FILLED WITH / ^ - SUB T REMAINING IN IN ATERIAL? ❑YES ❑NO /-/ JY OALLONB THIS FORM HAS BEEN COMPLETED UNDER PENALTY 6FPERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION a AGENCY a FACILITY ID N TANK ID R a 1,2 1 Ll 100 d CURRENrT LOCAL AGENCY FACILITY ID N APPRO ED BY NAME PHONE N WITH AREA CODE C. Y -r&i /U PERMIT NUMBER PERMIT APPROVAL DATE PE IT EXPIRATION DATE CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORM B Is-29-as) THIS FORM MUST BE ACCOMPANIEOVY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY