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STATE OF CALIFORNIA WATER RESOURCES CONTRA' BOARD FORM `B': UNDL-HGROUND STORAGE TANK PRCJURAM <J� TANK TANK PERMIT APPLICATION INFORMATION ` ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TAINK. Z 60 MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑7ANENTLY CL ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT E]6 TEMPORARY TANK CLOSURE B TANK REMOVED / n��p w FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1 [�W� FARM ANK-YES O ❑ N O 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY CD A. OWNERS TANK 10 N 7 B. MANUFACTURED BY: CD C.YEAR INSTALLED I D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ i UNLEADED ❑2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ M EMPTY 95 UNKNOWN ❑2 WASTE E] 7 METHANOL E:]99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.N C.A.S.N: III. 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 ❑ I SIEEUIRDN ❑2 STAINLESSSTEEL ❑3 FIBERGLASS ❑4 STEELCLADW/RBERGIASSREINFOIMPLASTIC B.TAMC ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL.. 9 BRONZE ❑ 10 GALVANIZEDSTEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ 1 RIBBERUNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 LN4UNFD ❑95 UNKNOWN ❑ B LINING MATERIAL COMPATIBLE WITH IM%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 RBERGUISS 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 I 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 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 B 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 E 1 VISUAL CHECK P E 2 INVENTORY RECONCILIATION P E 3 VADOSE WELLS P E 4 ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS 8 6 PRECISION TESTING P E 7 PRESSURE TESTING P E 91 NONE P E 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MONA) 2.ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLOND INERT MATERIAL? F-1YESE_ 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 5 SIGNATURE) DATE LOCAL AGENCY USE ONLY I COUNTY N JURISDICTION N AGENCY N FACILITY IDN TANK ID N IL AGENCY a l D 0 CURRENT LOCAL AGENCY FACT QID N v APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PGIMT IDPIRATM/M DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT By FORM B(6 29 68) THIS FORM MUST BE ACCO Lu Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY