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STATE OF CALIFORNit WATER RESOURCES CONTROI )ARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION V UMYLC I CA JCYAMA I C Y V NM WI I M I MC F VLLV W INU INF V HMA I IUN F V I4 CAUM I ANK MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EV5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TA ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT [-] 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 7o Q r--4 N t,#V geFARM TANK - YES �NO ❑ TANK DESCRIPTION COMPLETE ALL ITEMS -IF UNKNOWN -SO SPECIFY ��Z /'J A. OWNERS TANK ID# B. B. MANUFACTURED BY: UK, - ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL C, YEAR INSTALLED ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS D. TANK CAPACITY IN GALLONS: U II. TANK CONTENTS 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 F-11 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY & 95 UNKNOWN 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN REM D, BELOW) 0, IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED & C.A.S. M C.A.S. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, A D A. TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER5 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER A U ❑ 1 5TEELIIflON 25TAINLESS STEEL ❑ 3FIBERG 55 ❑ 4STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCIFE E ❑ 6 POLYVINYL CHLORIDE 7 INUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER A ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING n 4 B414OUC LINING C. INTERIOR LINING ❑ 5 GLASS LINING F]6 UNLINED C. MATERIAL ti.,�'V`5 UNKNOWN U 5ALUMINUM A ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT❑ NYL WRAP F-14 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION E]91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE 2. ESTIMATED QUANTITY Of 3. WAS TANK FILLED WITH FACILITY ID # A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 95 UNKNOWN A U 99 OTHER PHONE # WITH AREA CODE B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 95 UNKNOWN A U 99 OTHER SURCHARGE AMT. FEE CODE A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FISERGLASSPIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM A 1/ L'��B CONCRETE A U 7STEEL CLAD W/FRP A U 8100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A (UJe5 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 8 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 P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 PRECISION TESTING PRESSURE TESTING P S 91 NONE resr>s UNKNOWN P 8 99 OTHERUNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE W 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY Of 3. WAS TANK FILLED WITH FACILITY ID # SUBSTANCE REMAINING IN 1 INERT MATERIAL? F-1YES❑ ND GALLONS THIS F( HM MAS BtEN CVMYLE I EU UNUEH PLI AL 1 Y OF YEH IUHY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND C( APPLICANT'S NAME (PRINTED 8 SIGNATURE) DATE LOCAL AGENCY LISE ONLY RRECT. COUNTY # JURISDICTION # AGENCY # FACILITY ID # TANK ID # CURRENT LOCAL AGENCY FA�CJIL • 1 APPROVED BY NAME PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMITEXPIRATION DATE CHECK N PEgMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT # BY: FORM B (6-29-M) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A', UNLESS A CURRENT FORMA' HAS BEEN FILED 0