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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM " TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ Z MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 P NENTLYCL SEDTANK ONE ITEM ❑2 INTERIM PERMIT El AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED a CAP FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN co -SO SPECIFY A. OWNERS TANK ID 9 B. MANUFACTURED BY: (TS C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A ❑3 CHEMICAL PRODUCTL ❑4 OILROLEUM B;?'I PRODUCT C ❑4 GASAHOLD ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑SO EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7.METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) I D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.9 /V ' C.A.S.9: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ 1 DOUG EWALLED 713 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM WALLED ❑4 SECONDARYCONTAINMENT ❑99 OTHER T STEGUIRON ❑1 STAINLESSSTEEL ❑3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER UNED ❑2 NTNG F-13 EPDXY LINING ❑4 PHENOUC UNING LINING ❑5 GLASS LINING UNLINED 95 UNKNOWN ❑ IS LINING MATERULCOMPATIBLEWT(H 100%METHANOL? ❑YES ❑99 OMER D. CORROSION ❑ 1 POLYETHL64E WRAP ❑2 7W ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION 1 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A ASUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A 1 SINGLE WALLED 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 IWO) A U 4 RBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FAP A U 8 100%METHANOL COMPATIBLE FRP A U 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. ' PS 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 5 7 PRESSURE TESTING CID 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES E] 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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY 9 JURISDICTION# AGENCY 9 FACILITY ID N TANK ID 9 CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAM PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE 6ERMITliPIRATIOND CHECK# PERMIT AMOUNT SURCHARGE AMT. I FEE CODE RECEIPT# BY: FORM B F 29-eeTHIS FORM MUST BE ACCOMPANIEL WA FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CLTHRENT FORMA' HAS BEEN FILED S DATA PROCESSING COPY