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STATE OF CALIFORN WATER RESOURCES CONTR BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM `` TANKTANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z 1 O MARK ONLY ❑ 1 NEWPERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION RMANENTLY CL TA ONE ITEM ❑2 INTERIMPERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE utTANK REMOVE(( FACILITY/SITE NAME WHERE TANK IS INSTALLED: � , �['�{/yv FARM TANK-YES r co I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY o A. OWNERS TANK ID p I B. MANUFACTURED BY: LT, C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 5 O IL TANK C ,NfENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED Eq 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL 1 PROpUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS 1:15 HAZARDOUS ❑SO 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&CAS.p C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEELNRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBEBGLASS REINFORCED PLASTIC B.TANK F-15 CONCRETE ❑6 POLYVINYLCHLORIDE E]7 ALUMINUM F-18 100%METHMDL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER C. INTERIOR F1KYD I RUBBER UNED ❑2 ALUNING ❑3 EPDXY LINING r-14 PHENOLIC UNING Plg LINING ❑5 GLASS LINING ❑8 UNLINED -] UNKNOWN ❑ S LINING MATERIAL COMPATIBLE WITH 100%METHANOL' ❑YES NO ❑99 OTHER D. CORROSION ❑I POLYETHLWWIUP ❑2 TAR OR ASPHALT ❑3 VI WRAP ❑ 4 RBERGUSSREINFORCEDPLASTIC PROTECTION ❑5 CATHODIC PROTECTION 91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE 7i95 UNKNOWN A U 99 OTHER S.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE ArUj 95 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U SALUMINUM A 6CONCRETE A U ISTEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FPP A U 9 GALVANIZED STEEL A U 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. wlP 8 1 VISUALCHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S B PRECISION TESTING P 8 7 PRESSURETESTING P 8 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OLIANTITY OFOALLONB 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES E]YES 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 N JURISDICTION S AGENCY N FACILITY ID N TANK IO p ® = = oova CURRENT AGENCY FACILITY ID APPROVED BY NAME � PHONE 8 WITH AREA CODE PERMIT NUMBER PERMITAPPOVALDATE PE MIT EXPIRATION DATE III\UAYAI [CHECKS PERMIT AMOUNT SUPCHAPOE AMT. FEE CODE 1 RECEIPTS BY: FORM13(6-29-89) THIS FORM MUST BE ACCOMPANIED BY A FACILIPF/um APPUCATIOK FORM'A',UNLESS A CURRENT FORMA' HASBEENFILED DATA PROCESSING COPY