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STATE OF CALIFORNIA WATER RESOURC,Ey,CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM COMPLETE ;�� TANK TANK PERMIT APPLICATION INFORMATION TANK. COMPLA SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH0 z 10 MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWALPERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY DTAN ONE ITEM F-12 INTERIM PERMIT ❑<AMENDED PER IT ❑6 TEMPORARY TANK CLOSURE ANKREM o y FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3? FARM TANK-YES CA) I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CA3 A. OWNERS TANK IDK e. MANUFACTURED BY: ,- C» 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. 2l MOTOR VEHICLE FUEL ❑2 PETROLEUMC. ❑'-i UNLEADED ❑ 2 LEADED ❑ 3 DIESEL F-1 B,3 CHEMICAL PRODUCT ❑ /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 HAZARDOUS SUBSTANCE STORED&CAS.K C.A.S.K: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.8 D A. TYPE OF ❑ 1 BEE WALLED ❑3 SINGLE WALLED WITH FXTERIOP LINER ❑95 UNKNOWN SYSTEM 2 S 'WALLED ❑/SECONDARY CONTAINMENT ❑99 OTHER ETI STEELINION ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑/STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 C**LTE ❑6 POLYWM'LCHLORDE ❑ 7 ALUMINUM ❑B IOBAMETHANOL COMPATIBLE FRP MATERIAL ❑9 BIK)IIZE ❑ IB GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBERLINED ❑2 ALM LINING ❑3 EPDXY LINING ❑/PH IC UNING C. INTERIOR LINING ❑ 5 GLASS UNING ❑6 UNLINED UNKNOWN ❑B LINING MATERAL COMPATIBE WITH IIIBBMETHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLn7HIENE WRAP ❑2 7 ASPHALT ❑3 VINYL WRAP ❑/FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODC PROTECTION 91 NONE ❑95 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 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 U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 S TAINL RRE EES TTS EE STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U / FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 6ALUMINUM A UA U 6� A U 7STEEL CLAD W/FRP A U 810(196 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U 95 UN 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 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P E 3 VADOSE WELLS P ECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS \ P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 95 UNKNOW P S 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 SUBSTANCE REMAINING IN GELLLONf I 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 6 SIGNATURE) DATE \� LOCAL AGENCY USE ONLY [PERMCOUNTY N JURISDICTION S AGENCY K FACILITY ID K TANK ID K IT URRENT LOCAL AGENCY FACILITY ID S APPROVED BY NAME PHONE K WITH AREA CODE NUYBER PERMIT APPROVAL DATE PERMI PIRA I DATE CHECKS PERMIT AMOUNT -I SURCHARGEAMT. FEE CODE RECEIPTK BY: FORM 6(6-29-66) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS n JRRENT FORM'A' HAS BEEN FILED `'� DATA PROCESSING COPY