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STATE OF CALIFORNI WATER RESOURCES CONTR BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING)NFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT Zr5 CHANGE OF INFORMATION ❑7 PERMANENTLY CL NK ONE ITEM ❑2 INTERIM PERMR ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED jj FACILITY/SITE NAME WHERE TANK IS INSTALLED: Q/ , FARM TANK-YES 9 NO It 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPEC 10 A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: _34tPotp W 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. co A. '1MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED LEADED ❑ 3 DIESEL 1"t' ❑3 CHEMICAL PRODUCT ❑ 4 OIL 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 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.# C.A.S.W .III. TANK CONSTRUCTION MARK ONE ITIfM ONLY IN BOX A,B,C,a D A.TYPE OF ❑ 1POUBUE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGUSS REINFORCED PLASTIC B. TANK -1 5 CONCRETE ❑fi POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 1DO%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE E] 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ 1 RUBBMUNED ❑2 DLINING ❑3 EPDXY LINING ❑4 PHENOLIC UNING C. INTERIOR LINING 5 GLASS LINING 6 UUNLINED %UNKNOWN ❑ ❑ ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETIiIENEWRAP ❑2TAR ORASPHALT ❑3 W LWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLI BLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A OTHER B. CONSTRUCTION A U i SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 9 8 CONCRETE A U T STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 5 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. f A) P S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 6 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURETESTING P 8 1 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED D:a USED(MO/YR) 2. ESTIMATPD QUANTITY OF 3.WAS TANK EjLLED WITH SUBS GALLONS ,�J EMAINING IN INERT A YID? ❑YES ❑NO THIS FORM HAk BEEN COMPLETED UNDER PENALTY F PERJURY,AND TO THE BEST OF MY KNO ED E,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# Db U INI 1610loll CURRENT LOCAL AGENCY FACILITY ID p APPRO ED N E PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKN PERMITAMOUNT SURCHARGEAMT. FEE CODE RECEIPT N BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIEnf A FACILITY/SITE APPLICATION, FORM 'A',UNLESSA ENT FORMA' HAS BEEN FILED DATA PROCESSING C