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STATE OF CALIFORNij WATER RESOURCES CONTR`BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION o �" COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. oPv MARK ONLY F-1I NEW PERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION [—] 7 PERMANENTLY CLOSED TANK I O ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑. NK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO 4b, I. TANK D00ESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY � A. OWNERS TANK ID# B. MANUFACTURED BY: -4 C. YEAR INSTALLED t ciu5 D. TANK CAPACITY IN GALLONS: 560 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_ ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL F-13 CHEMICALPRODUCT IL F-11 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 60 EMPTY ❑ 95 UNKNOWN '£WASTE ❑7 METHANOL 9 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF ,,-A U,, HAZARDOUS SUBSTANCE STORED&C.A.S.# I,_0 L.C,ff 4 U) I C.A.S.H: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM �GLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER aT STEEL/IRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B IDA METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR F-] 1 RUBBER LINED ❑2 ALKYD LINING F-] 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING �D ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO � OTHER nj(.- D.CORROSION ❑ 1 POLYETHLENE WRAP ,�-TRROR ASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC 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 AU 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 U 5 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 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U UNKNOWN A U "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 CHECK8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTIN P 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 LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION k AGENCY N FACILITY ID# TANK ID# I d In I (1= I d nl d CURRENT LOCAL AGENCY FACILI IQ M APP U ROVED BY NAME PHONE M WITH AREA CODE l/JI/`'lxl l 5 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SUR CHARGE ANT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED ,A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A C ENT FORMA' HAS BEEN FILED DATA PROCESSING COPY T