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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM ' TANK TANK PERMIT APPLICATION INFORMATION m$m . COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ G MARK ONLY ❑i NEW PERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATIONn 7yERMANENTLY CLOSED TANK 1 ONE ITEM 2 INTERIM PERMIT ❑q AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE `- 6 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: C71 Kat*ZA.Aa_� FARM TANK-YES NO N I. TANKDESCRIPTION COMPLETE ALL ITEMS" IF UNKNOWN-SO SPECIFY W A. OWNERS TANK ID# 5B. MANUFACTURED BY: 00 C. YEAR INSTALLED. D. TANK CAPACITY IN GALLONS: Aft4u' ' IL TANK CONTENTS IF(A.1),18 MARKED,COMPLETE ITEM C.IF(AT),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 ❑ 1 PRODS ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑M EM Ptt UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED A C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D WALLED 3 INGLE A TYPE SYSTEM E]2 BNG�WALLED ❑4 SECONDARYWALLED CONTANMENT EXTERIOR LINER ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE n 7 366INUM ❑8 190%METHANOL COMPATIBLE FRP MATERIAL F] 79 BRONZE E] L /10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑1 RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXYLINING ❑4 ehENOUCUNING C LINING ❑ 5 GLASS LINING ❑6 UNLINED95 UNKNOWN ❑ ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT NYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, 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 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 LU,0195 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 A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL Y5 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. f)d j S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS �/ G P 9 6 PRECISION TESTING P S 7 PRESSURE TESTING 91 NONE P 6 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTI TED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTHY OF I 3. AS TANK FILLED WITH 5 E REMAINING IN GALLONS BIERT MATERIAL? ❑YES ❑ NO T S FORM HAS BEEN COMPLETED UNDER PENALfY 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# JURISDICTION# AGENCY# FACILITY ID# TANK ID# o / D e CU NT LOCAL ADEN AGILITY ID 4 APPROVED BY NAME / PHONE#WITH AREA CODE PERMIT NUMBER I/ PERMIT APPROVAL DATE P_EF1 IT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-86) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY