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STATE OF CALIFORNIA WATER RESOURCES CONTR(' BOARD FORM `B': UNDERGROUND STORAGE TANK PRO'G`RAM TANK TANK PERMIT APPLICATION INFORMATION (az COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYC ONE ITEM [ET2 INTERIM PERMIT F-14 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED G Z FACILITY/SITE NAME WHERE TANK IS INSTALLED: G/ FARM TANK-YES❑ NO .p. 00 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY cn A. OWNERS TANK ID# O Z I B. MANUFACTURED BY: A C. YEAR INSTALLED IA7S D. TANK CAPACITY IN GALLONS'. Z (�d 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. [01'MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C ❑ 1 UNLEADED Z2-2'LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT [-] 4 OIL 0<PRODUCT ❑ 4 GABAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) I D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# odz I A C.A.S.W III. TANK CONSTRUCTION MARK ONE ITEM O LY IN BOX A B,C,&D A. TYPE OF 0)" OUBLEWAUED F-13 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM M 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEELFIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 10096 METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ' 'LINING F-13 EPDXY LINING F-14 PHENOLIC LINING LINING F-15 GUSSUNING 6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IDO%pETWWOL? ❑YES ❑NO ❑M THER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 0 95 UNKNOWN ❑99 OTHER a IV. PIPING INFORMATION CIRCLE A IFABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A 1SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN 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 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 U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U S 1 OD%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A0095 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR 3 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 3 1 VISUAL CHECK f PI S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING 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 DAT[LAST USED(MO/YR) 2. ESTIMATED QUANTIlp OFGALLONSNB 3.WAS NK FILLED WITH SUBSTANCE RE A ININ E TERIAL? L-]YES ❑ NO A THIS FORM hAS BEEN COMPLETED UNDER PENALTY OF PERJUkY,AND TO THE BEST OF MY KNOWL DGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY TCOUTY# JURISDICTION# AGENCY# FACILITY ID# TAANK ID# N/ = = 16 1,0 1 l / /'/ CURRENT LOCAL AGENCYSS FACILITY ID N APPR V D Y NAME PHONE N WITH AREA CODE Sl u 1 PERMIT NUMBER PERMIT APPROVAL DATE MRmtr EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTN BY: I L$ FORM B(6-29-BB) THIS FORM MUST BE ACCOM BY A FACILITYYSITE APPLICATION, FORM 'A',U A CURRENT FORMA' KAS BEEN FILED DATA PROCESSING COPY