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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWINGmP FORMATION FOR EACH TANK. MARK ONLY ❑ i NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PE ENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIMPERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARYTANK CLOSURE ANKREMOVED ol FACILITY/SITE NAME WHERE TANK IS INSTALLED: v- FARM TANK-YES[-] NO •Q 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN SO SPECIFY A. OWNERS TANK ID# ��--- B. MANUFACTURED BY: C. YEAR INSTALLEDca D. TANK CAPACITY IN GALLONS: O II. TANK4MNTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COVCETE ITEM D. Wi A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. UNLEADED ❑2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 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.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A TYPE OF ❑ 1 DOUBLEW ❑ 3 SINGLE WALLED WITH EXTERIOR LINER F-195 UNKNOWN SYSTEM ❑2 SNGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON 2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ MATERIAL 5 CONCRETE 6 POLYVWYLCHLORIDE ❑7 ALUMINUM L] 100 8 %METHANOL COMPATIBLE FRP ❑ 9 8RONZEElll� GALVANIZEDSTEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑2 UNING ❑3 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑5 GLASS LINING ❑6 UNUN ❑95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%M NOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHAL ❑ 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, IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U / SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER S.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECON RV,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P E 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 XNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS 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# JURISDICTION# AGENCY# FACILITY ID N TANK ID N L41 ID d a 000 CURRENT OCAL AGENACILI M APPROVE AME %6-;6 PHONE#WITH AREA CODE hAJ PERMIT NUMBER PERMIT APPROVAL DATE PEAmrf EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORMS(S-29-BB) THIS FORM MUST BE ACCOMPANIED B ALITY/SITE APPLICATION, FORM 'A',UNLESSTF'NI)RRI9WT FORMA HAS BEEN FILED DATA PROCESSING COPY