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STATE OF CALIFORNI,- WATER RESOURCESCONTRC -30ARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE F B TANK REMOVED O FACILITY/SITE NAME WHERE TANK IS INSTALLED: e,i ch e FARM TANK-YES NO Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 000 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. Zi MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C L�Orl UNLEADED EADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑4 OIL d PRODUCT /7❑ 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&C.A.S.N NA C.A.S.#: XIII. 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 �[SINGLE WALLED ❑4 SECONDARi CONTAINMENT ❑99 OTHER 1 STEEUIRON ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK5 CONCRETE ❑6 POLYVINYL CHLORIDE7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑I RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑ 4 PHENOLIC UNING LINING ❑5 GLASS LINING ❑6 UNUNED UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. PROTECTION ❑ 5 CATHODIC PROTECTION [:]91TAR OR NONE ASPHALT F1 3 VINYL WRAP 4 FAWUNKNOWN 99 FIBERGLASS REINFORCED PLASTIC THER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A Q 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FAP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A105 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 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING 6ps 91 NONE- P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/VR) 2. ESTIMATED QUANTITY OfGALLONS 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. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION R AGENCY a FACILITY ID M TANK ID# ® OD 55S 10OO , CURRENT LOCAL AGENGFA^CILITY APPROVED BY NAMW PHONE WITH AREA CODEp U PERMIT NU ER PERMIT APPROVAL 6ATd I PERMIT EXPIRATION DATE CHECKX PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(3 7-w THIS FORM MUST BE ACCOMPANIEU dY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS)reRRENT FORMA HAS BEEN FILED