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STATE OF CALIFORM , WATER RESOURCES CONTRY BOARD FORM 'B': UNDMGROUND STORAGE TANK PRdtRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWI G INFORMATION FOR EACH TANK. _ Z .o.. MARK ONLY ❑ 1 NEW PERMIT F--] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION F-17 PERMANENTLY CLOSED TANK IC ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 0, FACILITY/SITE NAME WHERE TANK IS INSTALLED: - tl4T U FARM TANK-YES❑ NO Ca I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY Q0 00 A, OWNERS TANK 10 R. MANUFACTURED BY: W C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: �}OQ II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM A. EYMOTOR 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 ❑ 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 8 C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,6 D A. TYPE OF ❑ 1 DOUBLE WALED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑ 2 SINGLE WALED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 RBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RU88ER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS UNING ❑ 6 UNUNED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL' ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑1 POLYETHLENEWRAP ❑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 B. 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 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 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. P S 1VISUALCHECK P 8 2 INVENTORY RECONCILIATION P S 3VADOSEWELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OFGALLON8 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES [:] NO � THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE AWAN y5- PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE v _ CHECK# PERMIT AMOUNT SURCHARGE AMT. FEECODE RECEIPT# BY: r FORMS(6-29-66) THIS FORM MUST BE ACCOMPWIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA HAS BEEN FILED (\-, DATA PROCESSING COPY J