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STATE OF CALIFORN WATER RESOURCES CONTI BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSgQZ6UK ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED /o FACILITY/SITE NAME WHERE TANK IS INSTALLED: S FARM TANK-YES❑ NO I. TANK DESIf z CRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Q A. OWNERS TANK ID# G[q B. MANUFACTURED BY: C. YEAR INSTALLED V D. TANK CAPACITY IN GALLONS: 7�0II 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 ellPRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ 60 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.# A C.A.S.#. x111. TANK CONSTRUCTION MARK ONE I EM ONLY IN BOX A.B,C,8 D A.TYPE OF ❑� I DOUBLEWALLED F-] 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN L.CIy SYSTEM 4 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT 99 OTHER �5TEEL/IRON ❑ 2 STAINLESS STEEL ❑3FIBERGLASS ❑4STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL ❑5 CONCRETE ❑6 POLYWNYL CHLORIDE ❑7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑%UNKNOWN ❑ 99 OTHER C. INTERIOR F71 RUBBER LINED ❑2 ALKYD LINING F-13 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑ 5 GLASS LINING P6 UNLINED ❑95 UNKNOWN I ❑ ISUNING MATERIAL COMPATIBLE WITH ION METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCEDPLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ©91 NONE ❑ %UNKNOWN ❑%OTHER IV. PIPING INFORMAT ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U i SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A&1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U i STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE IPVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM AU 6 CONCRETE A U 7 STEEL CLAD W/FRP p U 810016 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR $ FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. ` 11 1iY P 8 / VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS NrN" P S 6 PRECISION TESTING P 8 '! PRESSURE TESTING P 91 NONE P S 95 UNKNOWN P 8 W OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED IMO/YR) 2. ESTIMATED QUANTITY OF 3, WAS T K FILLED WITH SUSSTANC INING IN INE ERIAL9 ❑YES ❑ NO GALLONS 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# JURISDICTION# AGENCY# FACILITY ID# TANK ID# do l33 goo /_ _ CURRENT LOCAL ApENCY FACILITY ID R APPR VED B NAM PHONE k WITH AREA CODE c� 2 zG PERMIT NUMBER PERMIT APPROVAL DA PERMIT EXPIRATION DATE CHECK R PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N FORM B(3-7AB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' NAS BEEN FILED JE G.,COPY