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STATE OF CALIFORN WATER RESOURCES CONTR BOARD FORM B': UNDERGROUND STORAGE TANK PROGRAM =m� TANK TANK PERMIT APPLICATION INFORMATION m,ro COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. I NEW PERMIT 3RENEWAL PERMIT 5 CHANGE OF INFORMATION E© MARK ONLY ❑ ❑ 7 PERMANENTLY CLOSED TANK❑ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: C r�T FARM TANK-YES❑ NO � N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CD N A. OWNERS TANK ID# B. MANUFACTURED BY: O C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL F]6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY [-]95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.R C.A.S.W III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CLAD WMBERGLASS REINFORCED PLASTIC MATERIAL B.TANK F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑61 OD%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR F-1I RUBBER LINED ❑2 ALKYD LINING F-13 EPDXY UNING ❑4 PHENOLIC UNING UNING ❑5 GLASS UNING ❑6 UMINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO E-]99 OTHER D.CORROSION ❑ 1 POLYETHIENE WRAP ❑2 TARORASPHALT ❑3 VIWLWRAP ❑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 L 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 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(FVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 10096METHANOLCOMPATIBLEFRP 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 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MONK) 2. ESTIMATED QUANTITY OF 3.WAS TANK RULED WITH SUBSTANCE REMAINING IN OALLOI/S INERT MATERIAL? ❑YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY IDM TANKID# EE El= = CURE LOCALACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE CAPEOBNCY FA PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEECOOE RECEIPT BY: FORM B(6-28-88) THIS FORM MUST BE ACCOMPANIE FACILDY/SITE APPLICATION, FORM 'A',UNLESS A'MAENT FORM W HAS BEEN FRW DATA PROCESSING CO