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STATE OF CALIFORNWATER RESOURCES CONTF BOARD FORM `B': UNDERGROUND STORAGE TANK PRlow OGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK.1 NEW PERMIT _ z MARK ONLY ❑ ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY a. K ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE FACILITY/SITE NAME WHERE TANK IS INSTALLED: O0 G(I =Qgl FARM �TANK-YES NO ❑ # I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 7 A. OWNERS TANK ID p B. MANUFACTURED BY: tl A C. YEAR INSTALLED f 1114-4D. TANK CAPACITY IN GALLONS: Q II. TANK g6NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A i MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. [—] 1 UNLEADED ❑2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OILRODUCT E]4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY [:]95 UNKNOWN E]2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.h C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A. TYPE OF ❑ I W LE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM LAKSINGUE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK F_�5 CONCRETE ❑6 POLYVINYLCHLORIDE � 7 AL MATERIAL IA ❑B 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 18 GALVANIZED STEEL EIKUNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD UNING ❑3 EPDXY UNING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING 6 UNUNED NKNOWN ❑ 19 UNING MATERIAL COMPATIBLE WITH 10D%METHANOL? ❑YES ❑ NO OTHER D. CORROSION F-1 1 POLYETELEME PROTECTION ❑5 CATHODIC PROTECCTTION ❑91TAR NONASPHALT F-13 VINYLNKNOWN ❑99FIBERGLASS REINfORCEO PLASTIC ER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A 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 UNKNOWN A U 99 OTHER A U I STEELPRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 IGD%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL f!P5 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 5 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P 6 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 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 ONO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION k AGENCY k FACILITY ID M TANK ID 8 mi = = I ol 'o / 10 D o CURRENT LOCAL AGENCY FACILITY ID�Y� APPROVED BY NAME PHONE M WITH AREA CODE S� GQ PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CXECKF PERMIT AMOUNT I SURCHARGE ANT. FEE CODE RECEIPTS BY:L.� FORM B(6-29-86) THIS FORM MUST BE ACCOMPANIbow?A FACILRY/SITE APPLICATION, FORM 'A',UNLESS ARWRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY