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STATE OF CALIFORNIP WATER RESOURCES CONTRC BOARD FORM `B': UNDERGROUND STORAGE TANK PROl RAM TANK ANK PERMIT APPLICATION INFORMATION COMP E A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. (az tO MARK ONLY 1 NEW PERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLYCLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED 0 FACILITY/SITE NAME WHERE TANK IS INSTALLED: _5-� FARM TANK-YES❑ NO .9h. I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-$O SPECIFY A. OWNERS TANK ID# I'-)- I B. MANUFACTURED BY: C. YEAR INSTALLED (,Cgtl� D. TANK CAPACITY IN GALLONS: 11. TANK CqNfENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,CO LETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM C. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ M EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF l V HAZARDOUS SUBSTANCE STORED&CA.S.# C.A.S.#: p(/ III. TANK CONSTRUCTION MARK ONE REM ONLY IN BOX A,0,C,&6 A.TYPE OF ❑ 1 EWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM SINGLEWAL ED ❑4 SECONDANCONTAINMENT ❑99 OTHER F71 1 STEEL/IRON E]2 STAINLESS STEEL FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑6 101%METHANOL COMPATIBLE FRP MATERUL ❑ 9 BRONZE ❑ 10 GALVANIZED 5TEEl ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 LINING F-13 EPDXY LINING ❑ 4 PHENOUCUNING LINING ❑5 GLASS UNING Eq,65NUMED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D PROTECTION ❑5 CATHODIC PROTECTION b2ASPHALT 95 VINYL WN 99RAP 4 FlOTHE USS REINFORCED PLASTIC IV. PIPING INFORMATION CIRCLE A IFAS GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 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 A U UNKNOWN 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 91 NONE C. MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AYQ�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. P 1VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P�5 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DAT LAS S ( /YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HA BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 06) / o C) CURRENT LOCAL AO CY FACILITY ID•, APPROVED BY WITH#WITH AREA CODE V PERMIT NUMBER PERMRAPPROV ATE PIkRMrr IIUTIOM DA CHECK# PERMIT AMOUNT I SURCHARGEOMT. I FEE CODE RECEIPT# BY: FORMB(6-29-88) THIS FORM MUST BE ACCOMPANI BYA FACILITY/SITE APPLICATION, FORM 'A',UNLESS A URRENT FORMA HASBEENFILED S DATA PROCESSING COPY