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STATE OF CALIFORNI: WATER RESOURCESCONTROI BOARD a FORM 'B': UNDERGROUND STORAGE TANK PROWRAM .TANK TANK PERMIT APPLICATION INFORMATION ` COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. G 10 MARK ONLY 1 NEW PERMIT F--] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM F-] 2 INTERIM PERMIT F-] 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED O ' FACILITY/SITE NAME WHERE TANK IS INSTALLED: �6 S, Q /V FARM TANK-YES NO Flor N 00 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY (V A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: O 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 DT43 DIESEL 3 CHEMICAL PRODUCT 4 OIL EP/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,CAS.# C.A.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ 1 DOUBLE WALLED F-1 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM D 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM F-� 8100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE D 10 GALVANIZED STEEL 95 UNKNOWN D 99 OTHER 1 RUBBER LINED E]2 ALKYD LINING 3 EPDXY LINING F-14 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING 7 6 UNLINED [::] 95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH I DD%METHANOL? YES ❑ NO ❑ 99 OTHER [D.CORROSION ❑ 1 POLYETHLENEWRAP 2 TAR OR ASPHALT F—] 3 VINYL WRAP E]4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION E]91 NONE ❑ 95 UNKNOWN E:] 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 STAINLESS STEEL 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 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 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 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH / SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? �YES D NO / ' THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF 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# W1 1 111,511111 / CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE#WITH AREA CODE Canso b PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 3 1 CHECK# PERMIT AMOUNT SURCHARGE AMY. FEECODERECEIPT# BY: FORMS(6-29-Be) THIS FORM MUST BE ACCOMPANIED BYA FACILITY/SITE APPLICATION, FORM 'A',—9 .ESS A CURRENT FORMA' HASBEENFILED ,� DATA PROCESSING COPY