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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION ® b. COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ MARK ONLY F-11 NEW PERMIT ❑3 RENEWALPERMR CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED I FACILITY/SITE NAME WHERE TANK IS INSTALLED: b �[Y FARM TANK-YES❑ NO EL� Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 1 A. OWNERS TANK ID# B. MANUFACTURED BY: (/ C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: W II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. EU440TOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. I UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OILODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ BO EMPTY [-]95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF A / HAZARDOUS SUBSTANCE STORED 8 C.A.S.# /17 C.A.S.#: / V All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C.a D A TYPE ❑ i DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER 1KNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMEM ❑99 OTHER ❑ 1 STEBUIRON 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 MEL CLAD W/RBERGUSS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9BRONZE ❑ fO GALVANIZED STEEL UNKNOWN ❑ 99 OTHER C. INTERIOR F-11 RUBBER LINED ❑2 ALKYD LINING F-13 EPDXY LINING F-14 PHENOLIC LINING LINING ❑5 CUSS LINING ❑6 UNLINED KNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TARORASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER (J' U B.CONSTRUCTION A U i SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL Yfjp5 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 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 3 VADOBE WELLS P f 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS N ' P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 1 NONE P 8 95 UNKNOWN P 8 W OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(M YR) 2. ESTIMATED QUANTITY 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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY IDN TANK ID# EN = = IrInlaI31 -fli CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME NEN LTH AREA CODE L R PERMIT APPROVAL DATE PERM EKPIR ON DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORMB(3-7-88) THIS FORM MUST BE ACCOMPANI YAFACILITTISREAPPLICATION, FORM'A',UNLESS ACURRENT FORMA' HASBEENFILED DATA PROCESSING COPY