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STATE OF CALIFORNIt WATER RESOURCES CONTRO" OARD FORM `B': UNDEftROUND STORAGE TANK PROGRAM TANK &�- TANK PERMIT APPLICATION INFORMATION TANK. Z COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 'GJ w FACILITY/SITE NAME WHERE TANK IS INSTALLED: (/�1/ /�� FARM TANK-YYEES NO O 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY / —4 A. OWNERSTANKID# 3 B. MANUFACTURED BY: O YEAR INSTALLED K D. TANK CAPACITY IN GALLONS: 11. TANK C TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D Cff] A. 1 MOTOR VEHICLE FUEL [:]2 PETROLEUM 0. . ❑ 1 UNLEADED 2 LEADED 3 DIESEL ❑ F-]3 CHEMICAL PRODUCT F-14 OIL 1 PRODUCT ❑ 4 GASAHOL ❑5 JEf FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C.A D A. TYPE OF ❑ t-16, BLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM LK 2SI14GLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑2 STAINLESSSTEEL ❑ 3 FIBERGLASS ❑ 4 STEEL GIADWIFlBERGLASR REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑81DD%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ 1 GLIBBER LINED ❑2 ALKYOUNING ❑ 3 EPDXY LINING ❑4 PHE UC LINING C INTERIOR ❑ 5 GLASS LINING ❑6 UNUNED UN LIN ❑ IS LINING MATERIAL COMPATIBLE WITH 1DD%METHANOL? ❑YES ❑ NO OTHER D. CORROSION ❑1 POLYETHLENE WRAP ❑2 TARORASPHALT ❑WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION E]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 NONEU 9 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 U 9 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 PPOER15LASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 6 ONCRETE A U 7 STEEL CLAD WIMP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEELi 79 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. S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 6 3 VADOSE WELLS P 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 1 PRECISION TE STING P S ] PRESSURE TESTING P S 91 NONE S 95 UNKNOWN P S 99 OTHER V1. 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 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# doil CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ;�✓ CHECK# PERMIT AMOUNT I SURCHARGEAMT. FEE CODE VECE1PT# BY. Foam B i6 29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY