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STATE OF CALIFORNI WATER RESOURCESCONTR( BOARD FORM 'B': UNDMGROUND STORAGE TANK PRO-GRAM W' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ^" Z e.o 10 f MARK ONLY ❑ 1 NEW PERMIT [-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑77PPERMANENTLY CLOSED TANK ONE ITEM F--] 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE P TANK REMOVED O q N FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO A LC 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N A, OWNERS TANK ID# - B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Lgoolo H. TANK 52NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. 14 - A. 1 MOTOR VEHICLE FUEL E] 2 PETROLEUM B. C. ❑ 1 UNLEADED El LEADED DIESEL E�K IL GAS ❑ 5 HAZARDOUS ODUCT OEMPTY 95 UNKNOWN ❑2 WAOSTTECT ❑7 METHANOL �O7HER(DESCRIBE❑IN TEM D?BELL 80 [-] OW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF I HAZARDOUS SUBSTANCE STORED 8 C.A.S.# F&c e / 0 i -- O/e-3e- D.A.S.#: b 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 Yaltil`NGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEUIRGN ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/RBERGLASS REINFORCED PLASTIC B TANK MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 1DD%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 AU(YD UNING ❑ 3 EPDXY UNING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS UNING ❑6 UNLINED UNKNOWN ❑IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYEfHLENEWPAP ❑2 TAR OR ASPHALT ❑3 VNft WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PflOTECTiON ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER 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 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 AOnUNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B /00%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A 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 8 2 INVENTORY RECONCILIATION P 3 3 VADOSE WELLS P S d ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 5 6 PPECISION TESTING P S 7 PRESSURE TESTING P 91 NONE P S 95 UNKNOWN P 6 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING INGALLONS 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# EH = O b l 3 3 O CURRENT LOCALLv AOENC FACT TTY IO a# APPROVED BY ME PHONE#WITH AREA CODE r' � 3 PERMIT NUMBER PERMIT APPROVAL DAT PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT I SURCHARGEAMT. FEE CODE RECEIPT# BY: FORM B S-29-99) THIS FORM MUST BE ACCOMPANIEL,III A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED 'TATA PROCESSING COPY