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STATE OF CALIFORNIA WATER RESOURCES CONTROI 'BARD FORM 'B': UNDEFMROUND STORAGE TANK PRO(AAM �� TANK TANK PERMIT APPLICATION INFORMATION P p COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - __ z 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY Cl-qaE K ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED /S N FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YESET NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY ~ A. OWNERS TANK IDA B. MANUFACTURED BY: 0 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: D II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. E3<`MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. UNLEADED ❑2 LEADED ❑ 3 DIESEL F13 CHEMICAL PRODUCT ❑4 OIL '{PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑90 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.R eo C.A.S.W 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 RJ�2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER R�1 STEELIIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CND W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 1 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑MOTHER C. INTERIOR F-1LKY 1 RUBBER LINED ❑2 AD LINING F-13 EPDXY LINING F-]4 PHENOUC LINING LINING ❑5 GLASS UNING ❑6 UNLINED 0,95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%MEFHANOL? ❑YES ❑ NO 099 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2TAR OR ASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ff95 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 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 AU 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U Z STEEL CUD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL 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 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 3 5 GROUND WATER MONITORING WELLS f S PRECISION TESTING P 5 7 TRESSURETESTING P S 91 NONE P B 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIM TED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAST NK FILLED WITH SUBSTANCE REM G IN INEfj ATERIAL? ❑YES ❑NO GALLONS J� TFhS FORM HAS BEEN COMPLETED UNDER PENALTY OF PE JURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY M0 nn V FACILITY ID# TT�A11NK ID# 12J3 � CURRENT LOCAL AGENCY FACILITY ID# APPROVED BYN E PHONE N WITH AREA CODE Aw--- /p ! f PERMIT MBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CRECK# PERMIT AMOUNT SURCHARGE AMT. FEECODE RECEIPT# BY: FORM616-29-BB) THIS FORM MUST BEACCOMPANIEDWAFACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORM'A' HASSEENFILED DATA PROCESSING COPY