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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT 3 RENEWALPERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED T K 10 ONE ITEM ❑ 2 INTERIM PERMIT F-] 4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE ❑S TANK REMOVED / FACILITY/SITE NAME WHERE TANK IS INSTALLED: , O FARM TANK-YES❑ NO N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: (n C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. 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 ❑/OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑60 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WAILED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON 2 STAINLESS STEEL F-13 FIBERGLASS F-1 4 STEEL CLAD W/FlBFAGLASS REINFORCED FUSTIC B.TANK ❑5 CONCRETE POLYVINYLCHLORIDE F-17 ALUMINUM ❑6100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 VANIZED STEEL ❑95 UNKNOWN ❑W OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYD ING ❑3 EPDXY UNING ID4 PHENOUCUNING LINING ❑5 GLASS LINING ❑6 UNUNEO ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPAT18LEWITH 100%METHA v ❑YES ❑NO ❑W OTHER D. CORROSION ❑ 1 POLYETHLENEWMP ❑2 TM 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 NDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE 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 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 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7 EELCLADW/FRP A U 8100%METHANOL COMPATIBLE PRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 O ER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDA PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MOM) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? [-]YES ENO] THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID N TANK ID# = = = 10 L 1 / 1917131 100 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NANIE PHONE N WTDI AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE I IIIIERMIT EXPIRATION DATE CHECKS PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT FARM B(6.29-Be) THIS FORM MUST BE ACCOMPANI A FACN.TTY/SITE APPLICATION, FORM 'A',UNLESS A COGNT FORMA' NAS BEEN FILED DATA PROCESSING COPY