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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM s>� TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. -_�` Z 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT E5 CHANGE OF INFORMATION ❑ 7 PERM=REMOVE / K ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK w FACILITY/SITE NAME WHERE TANK IS INSTALLED: 77 T-7 m FARM TANK-YE$ NO N I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY F-► A. OWNERS TANK ID# 62 1 B. MANUFACTURED BY: 00 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS, II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM A. Zl MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED Up LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑4 GASAHOL 5 FUEL ❑6 AVIATION GAS [-] 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE El METHANOL 99 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# (,4/ C.A.S.#:da C Z� III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN X A B,C,A D A. TYPE OF ❑ 1 OUBLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE PRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBERLINED ❑2 DUNING ❑ 3 EPDXY UNING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN N ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑2TAR OR ASPHALT ❑3 INYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:] 5 CATHODIC PROTECTION ❑ 91 NONE 0UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U SUCTION A U PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER S.CONSTRUCTION 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM ACONCPETE A U 7 STEEL CLAD W/FRP A U B 10METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A 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. .� P S I VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS I/ P 8 PRECISION TESTIN S , PRESSURE TE STING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTI TED DATE LAST USED(MO/YR) 2. ESTIM11EDQUANTITY OF 3.WAS TAN FILLED WITH SUBST C E T REMAINING IN INTRIAL? ❑YES ❑ NO AIIAGALLONS T IS FORM HAS BEEN COMPLETED UNDER PENALTY F PERJURY,AND TO THE BEST OF MY KNOWLE GE IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# sus' loU6 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BYN M� PHONE 0 WITH AREA CODE lti1 S� /S PERMIT NUMBER PERMIT APP11OVAL DATE PERMIT EX IRATION DATE CHECK4 PERM IT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORMB(6-29-BB) THIS FORM MUST BE ACCOMPANIEVOAFACILRTISITE APPLICATION, FORM 'A',UNLESS A RENT FONW HAS BEEN FILED DATA PROCESSING COPY