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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'B'- UNDERGROUND STORAGE TANK PROGRAM ` <br /> ANK PERMIT APPLICATION INFORMATION b <br /> TANK kcOmPLETET <br /> A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK, <br /> MARK ONLY 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK <br /> ID <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED <br /> I Ln <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 2D 8 I , FARM TANK-YES❑ NO LK N <br /> -7v 4b. <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 4 <br /> A. OWNERS TANK ID If ! B. MANUFACTURED BYG <br /> : � <br /> C.YEAR INSTALLEDvz- D. TANK CAPACITY IN GALLONS: ,V <br /> 11. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM BB <2WASTE <br /> C. ❑ 1 UNLEADED LEADED ❑3 DIESEL <br /> F-13 CHEMICAL PRODUCT ❑ 4 OILPR <br /> PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS <br /> ❑ 5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑7 METHANOL ❑99 OTHER(DESCRIBE IN REM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,0,C,&1) <br /> A TYPE OF ❑ I DOUBLE WAUED F-13 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN <br /> SYSTEM YJ`sSING WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER <br /> 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK ❑5 CONCRETE E]6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER <br /> ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑4 PHENOLIC LINING <br /> C.`IN NRIIOR ❑ 5 GLASS LINING ❑6 UNLINED ER 5 UNKNOWN <br /> ❑ ISUNING MATERIAL COMPATIBLE NTH 100%METHANOL? ❑YES ❑ NO 90THER <br /> D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TARORASNALT ❑3 WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER <br /> IV. PIPING INFORMION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A SYSTEM TYPE U / SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE Ab 95 UNKNOWN A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A {I'{CONCRETE A U 7 STEELCLAD W/FRP A U 8100%METHANOL COMPATIBLE RAP <br /> A U 9 GALVANIZED STEEL A "S UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR 8 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P 5 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> 00 P 8 8 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 =ELECTRONIC <br /> P' 8 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED OUANTFTY OF 3. WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES 0N <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> E� ° / <br /> CURRENT LOCAL AGENCY FACILITY ID t APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMITNUMBEN c PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ' I <br /> ll <br /> 5 3 Cl CHECK# PERMIT AMOUM SURCHARGE AMT. FEE CODE RECEIPT# BY: <br /> 7 FORM B(s-z9-BB) THIS FOAM MMTI E ACCOMP BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS CURRENT FORMA' HAS BEEN FILED /1J V) <br /> DATA PROCESSING COPY <br />