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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. - MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK I� ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED / H FACILITY/SITE NAME WHERE TANK IS INSTALLED: v I �'yOS-S. FARM TANK-YES❑ NO N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N A. OWNERS TANK ID# B. MANUFACTURED BY: N C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: epz)�r II. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM 91 A. Ef 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL B. ❑ 3 CHEMICALPRODUCT ❑ 4 OIL PRODUCT ❑4 GASAHOL ❑ 5 JET 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 HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.It: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ 1 DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARYCONTAINMENT ❑99 OTHER ❑ 1 STEBUTION ❑2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PlA5RC B. TANK MAMATERIALF-15 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZEDSTEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNUNED 95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL9 ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TARORASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC 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 DNED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP 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. P 5 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P & 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P 6 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OFGALLONS 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY ENIIIN�T�YJ# II JURISDICTION# AGENCY# FACILITY ID A TANK ID# CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE p WITH AREA CODE 2 PERMIT NUMBER PERMIT APPROVAL DATE PERMITEXPIRATION DATE CHECK# PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: KSS Ut FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIEDFACILITY/SITE APPLICATION, FORM 'A',UNLESS 1 ENT FORMA' HAS BEEN FILED DATA PROCESSING COPY