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STATE OF CALIFORN" WATER RESOURCES CONTR BOARD FORM 'B': UNDORGROUND STORAGE TANK PROGRAM v 4 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 PERMANENTLYCLO TANK ONE ITEM ❑2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED O/ N FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-VES NO (J7I N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO FY (,V 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.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT r2O1L ❑ 1 ADDUCT ❑4 GASAHOL ❑ 5 J FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN WASTE ❑7 METHANOL 99 OTHER(DESCRIBE TEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# bjC.A.S.#: D III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,8 D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEMSINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC j B.TANK ❑ 5 CONCRETE ❑8 POLYVINYL CHLORIDE MATERIAL F-17 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑98 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2AMLINING ❑ 3EPDXY LINING ❑4 PHENOLIC UNING LINING ❑ 5 GLASS UNING �6 UNUNED ❑ UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH IUD%METHANOL? ❑YES E:] NO IOTHEfl JA&41J O. CORROSION ❑ 1 POLYETHLENE WRAP 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 IF ABOVE GROUND, U IF UNDER OUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 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 STEEL/IRON 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 8 CONCRETE A U 7 STEEL CLAD W/FBP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U 95 UNKNOWN A U 99 OTHER �I V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS ll P 6 PRECISION TESTINGO: 7 PRESSURE TE STING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. EST MATED DATE LAST USED(MO/YR) 2. ESTIM EO QUANTITY OF 3. WAS ANK FILLED WITH SUBS N REMAINING IN ATERIAL? ❑YES ❑ NO I GALLONS TIS FORM HAS BEEN COMPLETED UNDER PENALTY10F 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# cap � oc� � CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY N ME PHONE#WITH AREA CODE Lod 1- u "X PERMIT NUMBER PER IT APPD TE PERMITE PIRATION DATE �t 1L CHECKN PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTN BY: �4; FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A MRRENT FORMA' HAS BEEN FILED ,ESSING C'_