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STATE OF CALIFORNP WATER RESOURCES CONTR BOARD FORM 'B'- UNDERGROUND STORAGE TANK PROGRAM TANK v,/ TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. '"' Z 10 MARK ONLY F-11 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION j 7 PE NENTLY C ONE ITEM ❑ 21NTERIMPERMIT ❑1 AMENDED PERMIT/ ❑ 6 TEMPORARY TANK CLOSURE ANK REMOVE FACILITY/SITE NAME WHERE TANK IS INSTALLED: S5 ZO�2 FARM TANK-YES❑ NO IV I. TANK DESCRIPTION COMPLETE ALL ITEMS•IF UNKNOWN-SO SPECIFY 9s �� o A. OWNERS TANK IDN B. MANUFACTURED to C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: U II. TANK CONTENTS IF(A1),18 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED [Tr2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑A OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS [:35 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 8 C.A.S.N C.A.S.X III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF ❑ I DOUBLEWALLED ❑3 SINGLE WALLED MTH EXTERIOR UNER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑/SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEL NON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑ A STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC S.TANK ❑ 5 CONCRETE ❑6 POLYVINYL CILORDE ❑ 7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP MATERIAL.. 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑X PHENOLIC LINING LINING ❑ 5 GIASSUNINO ❑6 UNLINED ❑95 UNKNOWN ❑ IS LWINO MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETRENEWRAP ❑ 2 TAR OR ASPHALT ❑3 VINYL WRAP ❑ 1 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 8.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U W OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U I FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEEL CLAD W/FOP A U 8100%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 { 1 VISUAL CHECK P t 2 INVENTORY RECONCILIATION P t 3 VADOSE WELLS P { 1 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS { 8 PRECISION TESTING P { 7 PRESSURE TESTING P t 91 NONE P { 95 UNKNOWN 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 INGALLONt 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION t AGENCY N FACILITY ID N TANK ID N M] = = © s v CURRENT LOCAL AGENCY FACILITY ID N to A P �j APPROVED BY NAME PHONE I WITH AREA CODE PERMIT NUMBER !L' /PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK N PERMIT/MOUNT {URCHARGE AMT. FEE CODE RECEIPT I By FGRM B(6-29-MI THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED