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STATE OF CALIFORN` WATER RESOURCES CONTR FORM 'B'= UNDERGROUND STORAGE TANK PROGRAM - 1- TANK TANK PERMIT APPLICATION INFORMATION $® P 1 COMPLETE A SEPggqTE FORM W17H THE FOLLOWING INFORMATION FOR EACH MARK ONLY ❑ 1 NEW PERMIT TANK. ONE ITEM ❑3 RENEWAL PERMIT C p INTERIM PERMIT ❑4 5 CHANGE OF INFORMATION AMENDED PERMIT117 PERMANENTLY TANK i O FACILITY/SITE NAME WHERE TANK IS INSTALLED: ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVE I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO ��.5 Ory FARM TANK-YES NO ❑ PEARINSTALLED WNERS TANK ID# SO SPECIFY B. MANUFACTURED BY D TANK II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A,),IS NOT MARKED,COMPLETE ITEM D. sr� A. ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ i UNLEADED 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT Ej 4 OIL ❑ 1 PRODUCT ❑4 GASAHOL 5 JET FUEL ❑5 HAZARDOUS ❑80 EMPN 95 UNKNOWN 2 WASTE ❑ ❑6 AVIATION GAS ❑ ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,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 ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER F-71 STEEL/IRON ❑2 STNNLESS STEEL ❑3 RBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7% MINUM ❑B 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑10 GALVANIZED STEEL UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER UNED ❑2 ALKID LINING ❑3 EPDXY UNING ❑ 4 P OLICUNING LINING ❑5 GLASSUNING ❑6 UNUNED %UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IOD%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYEMLENEWRAP ❑2 TAR OR ASPHALT 3JWtWRAP ❑4 FIBERGLASS REINFORCED PLASTIC 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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U UNKN 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 UNKN WN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 9/ NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A U NKNOWN 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 3 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 95 UNKNO N P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID N C NT LOCAL AGENCY FACILITY IDN APPROVED BY NA PHONE N WITH AREA CODE PERMIT NUYBE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AML FEE CODE RECEIPT N BY: l0 FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY