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STATE OF CALIFORNF WATER RESOURCES CONTR/�c ;D FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK COMPLETEATANK N KPERMINIPERMITAPPLICATION INFORMATION LLOWING WITH RMATIION OR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM 1 O ❑2 IN PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: S. FARM TANK-YES NO ❑ N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY cil A. OWNERS TANK ID# � B. MANUFACTURED BY: 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 ❑ i MOTOR VEHICLE FUEL 0 2 PETROLEUM B. C ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT 4 OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑SO 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 A CAS.# CA.S.#: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,A D r$YSTEM E OF ❑1 OOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN ❑2 SINGLE WALLED ❑4 SECONDARY OT INMEM ❑gy pTM� K 1 STEEL/IRON ❑2 STAINLESSSTEEL ❑3 RBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED FUSTICERIAL ❑5 ❑8 POLYVINYL CHLORIDE ❑7 INUM ❑B 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99ROTHER LI C. INTERIOR ❑ I RUBBER LINED ❑2 ALKVO LINING ❑3 EPDXY LINING ❑/ CLINING LINING ❑5 GLASS LINING ❑6 UNLINED ,UL—,'9 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TARORAW14ALT Q 3y WRAP ❑4 RBEAGLASSREINFORCEDPLASRC 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 95 UNKN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE IPM A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U SCO E A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A UNKN 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. 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P8 4 ELEC NIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P $ 5 UNKNOWN P 8 99 OTHER V1, INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR1 2. ESTIMATED OLIANTITV OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN ONS INERT MATERIAL? F-1YES F-1NO GALL 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# # TANK ID# 3 �- � o © o i C LOCAL AGENCY FACILITY ID# APPROVED BY PHONE#WITH AREA CODE PERMITNUM PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# Sy; FORM B(6-29-ee) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COP'.