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STATE OF CALIFORNIA WATER RESOURCES CONTROL S- "'RD FORM 'B': UNDERGROUND STORAGE TANK PROGFMM =mom TANK TANK PERMIT APPLICATION INFORMATION COM5M A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _- Z 10 MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED C7 FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO (� 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN VsOSPECIFY 00 A. OWNERS TANK ID# B. MANUFACTURED BY: d C. YEARINSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. 2 LEADED E5'3DIESEL A F-1 3 CHEMICAL PIRODUCTL 4 POOILETROLEUM 8. 1 PRODUCT C E]4 GASAHOLD ❑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.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 INUM ❑8 lw%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING [b:1];4 PH LINING LINING F-15 GLASS LINING ❑6 UNLINED UN WN ❑ ISUNING MATERIAL COMPATIBLE WITH TDO%METHANOL? ❑YES ❑ NO OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINY F] 4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:] 5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER I B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD WERE A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL ACt 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 1 VISUAL CHECK 8 2 INVENTORY RECONCILIATION P 8 3VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 5 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LA$ U�O/YR) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH N 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# TANK ID# 3 � CURRENT LOCAL AGE YFACb ILITY IDK APPROVED BY NAME PHONE*WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PE MIT XPIRATION TE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(5-29-m) THIS FORM MUST BE ACCOMPANIt;:RY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A.,1IRENT FORMA' HAS BEEN FILED / DA'`A '-40CFSSINC CI)PY