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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD T FORM 'B': UNDERGROUND STORAGE TANK PROGRAM6 �= TANK TANK PERMIT APPLICATION INFORMATION ,m COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. _ z 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 FERMANENTLYC ED TANK 1 IO MARK ONLY F-1JI ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVE FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES NO (y I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N A. OWNERS TANK ID# �,� B. MANUFACTURED BY: k-p N C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS' 5�40d 11. 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 PETROLEUMB. C. ❑ 1 UNLEADED 2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT E]4 OILVNOWN 1::11 PRODUCT 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑ ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# CAS #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY I BOX A.B,C,A D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH RIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARYOONTAINM ❑ 99 OTHER 1 STEEL/IRON 2 STAINLESS STEEL 3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B. MATERIAL ❑5 CONCRETE ❑fi POCNINYL CHLORIDE ❑ LUMINUM ❑B 100%METHANOL COMPATIBLE FOP ❑ 9 BRONZE ❑iD GALVANIZED STEEL 95 KNOWN 99 OTHER J C.INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPO INING ❑ 4 PHENOLIC UNING LINING ❑5 GLASS LINING ❑6 UNUNED ❑95 UNKNOWN ❑ ISUNING MATERIALCOMPATIBLEWITH 100%METHANOL? YES ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP 2 TMORASPHALT 3 VINYL WRAP 4 RBERGLISS REINFORCED PLASTIC PROTECTION D 5 CATHODIC PROTECTION 91 NONE E]95 UNKNOWN 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, V IF UNDERGROUND,B TH 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 9/ NONE A U 95 UNKNOWN A U 99 OTHER A U i STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLO DE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U S ALUMINUM A U 6 CONCRETE A U ]STEEL CLAD W/FR A U B 10096 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U W OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY.A PRIMARY\bfAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MO TOR P S S GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? DYES ❑ 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# 10101 / X75 00 CURRENT LO AL�CY FACILITY ID# APPR OVED Y NAME ./Y0 PHONE#WITH AREA CODE L S I IL�- PERMIT NUMBER PERMIT APPROVAL DATE P RMIT EXPIRATION DATE CHECK# I SURCHARGE AMT. FEE CODE RECEIPT BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIEVVY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY