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STATE OF CALIFORNI ^ WATER RESOURCES CONTRO' BOARD FORM `B': UNDERGROUND STORAGE TANK PRO!"AM TANK TANK PERMIT APPLICATION INFORMATION ~' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. --_ 10 MARK ONLY ❑ NEW PERMIT F-13 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO EDTA ONE ITEM V2 INTERIM PERMIT F-14 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED O Z N FACILITY/SITE NAME WHERE TANK IS INSTALLED: (JI i FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# O B. MANUFACTURED BY: C. YEAR INSTALLED �j D. TANK CAPACITY IN GALLONS: fl7 n II. 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 ❑2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 4 GASAHOL ❑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 0 HAZARDOUS SUBSTANCE STORED 8 C.A.S.# C.A.S.#: A/ III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A. TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLEWALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM F 2 SINGLE WALLED ❑4 SECON JAM CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESSSTEEL 3 FIBERGLASS F-]4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYV LGHLORIDE F-17 ALUMINUM ❑B 100%METHANOL COMPATIBLE FHP MATERIAL ❑9 BRONZE ❑ 10 GALV�.NI2ED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR 1 RUBBER LINED ❑2 A NTNG F-13 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING 6 UNLIN ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLEWITH 10D% 0L? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR CP ASPHALT 3 WWLWRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NON ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF AB VE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A I SUCTION 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 AI�6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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 1VISUAL CHECK 8 21NVENTORY RECONCILIATION P 5 3VADOSE WELLS P S 4ElECTRONIC MONITOR P S SGROUND WATER MONITORING WELLS l P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE IST USED(MO/YR) 2. ESTIMATED OU NTITY OFOALLONB 3.WAS TANK FlpXD WITH SUSSI R AINING IN INERT MAT I L? [—]YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF P RUURY,AND TO THE BEST OF MY KNOWLEDGit,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# by r 1 yr 1 C) I r CURRENT LOCAL AGENCY FACILITY ID# APP V D Y NAME /yj PHONE#WITH AREA CODE �, evSC2. 1/ 1 PERMIT NUMBER PERMIT APPROVAL DATE PE MITE PIRATION DATE CHECK# PERMIT AMOUNT SUflCHAgGE AMT. FEE CODE RECEIPT# BY: .\ FORM B 16.29 561 THIS FORM MUST BE ACCd ANIED BY A FACILITY/SITE APPLICATION, FORM `A',U, A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY