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STATE OF CALIFORN! WATER RESOURCES CONTR BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM " TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. a• MARK ONLY ❑ i NEW PERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PE ANEN7LV CLOSED 7A to ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ANK REMOVED a FACILITY/SITE NAME WHERE TANK IS INSTALLED: -5371 FARM TANK-YES❑ NO ❑ Cn N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IDN B. MANUFACTURED BY: L2 C4 C. YEAR INSTALLED D. TANK CAPACITYIN GALLONS: II. TANK CqXTENTS 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 ❑4 OIL 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 6 CAS.N CAS.M 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 LINER EDOk UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 AL M ❑610016 METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER C. INTERIOR F-11 RUBBER UNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PH CLINING LINING F-15 GLASS UNING ❑6 UNLINED UNKNOWN ❑ IS UNING MATERNLCOMPATIBLEWITH 100%METRANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:] 5 CATHODIC PROTECTION ❑91 NONE NKNOWN -]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 5 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNEDTRENCH A U 91 NONE UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM ANGCONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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. vsAlP 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3VADOSEWELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MOLAR) T 2. ESTIMATED QUANTITY OFOALLONB 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID R ENI � � CURRENT LOCAL AGENCY FACILITYID N J APPROVED Y NAM �f� PHONE N WITH AREA CODE 1 vS Y/L� PERMIT NUMBER PERMIT APPROVAL DATE / I PYRMITEkPIRATION DATE CRECKN PERMIT AMOUNT SURCHARGEAMT. FEECODE RECEIPT N BY: FORMB(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM'N,UNLESS A CURRENT FORM'A' HASSEENFILED DATA PROCESSING COPY