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STATE OF CALIFORK % WATER RESOURCES CONTI . BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM T � TANK TANK PERMIT APPLICATION INFORMATION m �. COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. — MARK ONLY ❑ 1 NEW PERM'T ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 10 ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE f 8 TANK REMOVED .09 FACILITY/SITE NAME WHERE TANK IS INSTALLED: 2,-7 _ pL, FARM TANK-YES NO ❑ N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N A. OWNERS TANK IDp - B. MANUFACTURED BY'. C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: / 1521 fo II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A F-1 3 CHEMICAL PIRODUCTL ❑ 4 OIL ROLEUM B 1 PRODUCT C ❑ 4 GNASAHOLD ❑5 JETD DFUEL ❑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.R GAS.R: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,&D A TYPE OF ❑1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER F-11 STEBUIRON ❑2 STAINLESS STEEL ❑3 RBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE [_-]7 AL INUM ❑810096 METHANOL COMPATIBLE FRP F]9 BRONZE ❑10 GALVANIZED STEEL UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBERUNED ❑2 AUKYDUNING ❑3 EPDXY LINING ❑4 PHENOUCUNING LINING ❑5 GLASSUNING ❑6 UNLINED 04 UNKNOWN ❑ IS UNNG MATERIAL COMPATIBLE WITH/00%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑I POLYETHLFNE WRAP ❑2TAR OR ASPHALT ❑3W WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 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 AQ4J b5 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED -A-U 3 LINED TRENCH A U 91 NONE UUNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUMA U^6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL : BS 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 8 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 8 5 PRECISION TESTING P 8 7 PRESSURE TESTING 91 NON P 8 95 UNKNOWN P S 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 INGALLONS 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 COUNTY N JURISDICTION N AGENCY R FACILITY ID R TANK ID# CURRE OCAL AGENCY FACILITY ID E APPROVED BY y7e PNONE N WITH AREA CODE O P /� PERM NUMBER PERMIT APPROVAL DATE Pdamrr EXPIRATION DATE CHEGKk PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTB BY: FORM e(s-29-ee) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY