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STATE OF CALIFORNIA_ WATER RESOURCES CONTROL "ARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM o ` TANK TANK PERMIT APPLICATION INFORMATION ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z MARK ONLY 1 NEW PERMIT 3 RENEWALPERMIT o• 1 O ❑ ❑5 CHANGE OF ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑e TANK REMOVEDPa D FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY EN A. OWNERS TANK 10# B. MANUFACTURED BY: V C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: U 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. E:] 1 UNLEADED [21 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT [—]4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN E]2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF I HAZARDOUS SUBSTANCE STORED 8,C.A.B.N11A C.A.S.N: eLILA III. TANK CONSTRUCTION MARKONE ITEM ONLYIN BOXA,B.C,BD A.TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM t❑i P SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 1004METHANOL COMPATIBLE FRP ❑ 9 BRONZE 0 10 GALVANIZED STEEL ❑95 UNKNOWN ❑W OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING 2 ONUNED ❑95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 1004 METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLBIE WRAP Z2 TAR OR ASPHALT ❑3 AWL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODICPROTECTION ❑91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPEA U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95'UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINUGLE 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 STEEL/IRON 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 CONCRETE A U ] STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE TAP A U 9 GALVANIZED STEEL A LL 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 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS SZ PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMAT2 DATE LAST USED(MON 2. ESTIMATED O NTITY OF 3.WAS ANK FILLED WITH 1 SUBSTANC WING IN TERIAL? ❑YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF 9ERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N d 11 1 ( O 10 3 CURRENT LOCAL AGENCY FACILITY ID 4 APPROVED BY AME PHONE M WITH AREA CODE � , Ai. ,," h �9 L PERMIT NUMBER PERMIT PERMIT EXPIRATION DATE CHECK# PERMITAMOUNT SURCMAR E FEE CODE RECEIPTR BY: \I FORM R(s-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED _ DATA PROCESSING COPY