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STATE OF CALIFORNIA WATER RESOURCES CONTROL ')ARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM ;®� TANK TANK PERMIT APPLICATION INFORMATION � 3 COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 10 MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 RMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-VES❑ NO N W I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C) C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS:6 d II. TANK NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL DUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM O,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 ❑ DOUBLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER E] 95 UNKNOWN SYSTEM SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEURON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL ❑5 CONCRETE ❑8 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR [__11 RUBBER UNED ❑2 WMUNING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑5 GLASS UNING 6 UNLINED ❑ UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHMOL? ❑YES [:] NO WOTHER " L(., O. CORROSION 1 PROTECTION ❑5 CATHODICEPROTECTION NEWRAP ❑91 NONE ASPHALT 95V KNOWN E]99 OTHER REINFORCED PLASTIC IV. PIPING INFORMA N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE EMAERRIALY PE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER TION A U 1 SINGLEWALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE A 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A�9 GALVANIZED STEEL A U 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. hle. P 5 1 VISUALCHECK P S 2 INVENTORY RECONCILIATION P 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S B PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE ESTIMATED DATE LAST USED(MO/YR) 2 ESTIM TED QUANTITY OF 3. AS TANK FILLED WITH S B CE REMAINING IN GALLONS T MATERIAL? ❑YES [:]NO THIS FORki HAS BEEN COMPLETED UNDER PEN OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANTSNAM E(PRINTED&SIGNA RE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID#�/ h TANK ID# / TY CURRENT LOCAL AGENCY FACILITY ID# APPR l VEO BY AME PHONE#WITH AREA CODE 6 �3 - PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATI N DA CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIEL aY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS JOLVARENT FORMA HAS BEEN FILED