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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 INFORMATION FOR EACH TANK. ___ _ Z MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C T NK f0 ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: S FARM TANK-YES❑ NO F N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY IV A. OWNERS TANK ID# 8. MANUFACTURED BY: F••a C. YEAR INSTALLED JD. TANK CAPACITY IN GALLONSdo II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. I MOTOR VEHICLE FUEL F-1 2 PETROLEUM B. C. 1 UNLEADED 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL / E1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS IOEMMPTY ❑95 UNKNOWN E:12 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE EL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ OUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM LEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEUIRON ❑25'TAINLESS STEEL r_13 FIBERGLASS F-14 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL S. TANK ❑5�CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM 81 OD%METHANOL COMPATIBLE FRP I--T ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL -.LJ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBERUNED ❑ 2 ALKYDUN#t' f ❑3 EPDXYLINING ❑4 PHENOLIC UNING LINING ❑5 GLASS LINING �6UNLINED ❑95 UNKN07, ❑ IS LINING MATERIAL COMPATIBLE WITH 101)%METHANOL? ❑YES ❑ NO �R)OTHER I D. CORROSION ❑ 1 POLYETHLENE* P/ ❑2 TAA OR ASPHALT ❑ 3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE e-95 UNKNOWN ❑99 OTHER IV. PIPING INFORMA ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A 2 PRESSURE A 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 U 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 3 POLYVINYL CHLORIDE(PVC) A U 4 FISERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM Afi CONCRETE A U 7 STEEL CLAD W/FRP A U S 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A U 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. P 5 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S S PRECISION TESTING S 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER 6 VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMAT DATE LAST USED(MO/YR) 2. ESTIMATE QUANTITY OF 3, WAS T NK FILLED WITH �j SUB A XEMAINING IN INER M TERIAL? [-]YES NQ Y � !� GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWL DGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATUREI DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# O I 0 I / - 6 I d I U D l CURRENT LOCAL AGENCY FACIA ID# APPROVEL)BY NA /� ` PHONE#WITH AREA CODE S N(fL PERMIT NUMBER PERMIT APPROVAL DATE PERMIT tEXPIRATION DATE CHECK# PERMITAMOUNT SURCHARGEAMT. FEECODE RECEIPT# BY: \I FORM B E-29-e&) THIS FORM MUST BE ACCOMPANIE_DW6 A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A MRRENT FORMA' HAS BEEN FILED T "*mac PAOCESSING COPY