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STATE OF CALIFORPN{A WATER RESOURCES CON L BOARD FORM 'B': UNMERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION n 7 pFJiMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARYTANKCLOBURE L�y�,'B/ O TANK REMOVED FFyy FACILITY/SITE NAME WHERE TANK IS INSTALLED: G FARM TANK-YES❑ NO 4c4 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N� A. OWNERS TANK IDN B. MANUFACTURED BY: C. YEAR INSTALLED L( D. TANK CAPACITY IN GALLONS: O II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. ila A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM kl C. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL RODUCT 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS 5 HAZARDOUS ❑60 EMPTY ❑ 95 UNKNOWN ASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME F HAZARDOUS SUBSTANCE STORED 8 C.A.S.N C.A.S.N' III. TANK CONSTRUCTION MARK ONE 4M ONLY IN BOX A,B,C,S D A TYPE OF ❑ 1 BLE WALLED ❑3 SIN LE WALLED WITH EXTERIOR LINED E] 95 UNKNOWN SYSTEM LE1 SINGLE WALLED ❑4 SECO ARY CONTAINMENT ❑99 OTHER F-] 1 STEEL/IRON ❑ 2 STAINLE STEEL E]3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B. MATERIAL ❑5 CONCRETE ❑6 POLYVINYL LORIDE ❑ 7 ALUMINUM ❑ 8 10D%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED TEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER UNED ❑2 ALKYD LINING Fl3 EPDXY LINING [:] 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 10D%METHANOL? ❑YES ❑NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑ 2 TAO OR 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 NDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE 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 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 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A 7 STEEL CLAD W/FRP A U B 100%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 SE NDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 3 1 VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S M UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLAC 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO TH BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N = = = DO11 135a I DOD CURRENT LOCA AGENCY FACILITY IDN APPROVE BY NAE^10 p(A/T PHONE N WITH AREA CODE `1 PERMIT NUMBER PERMIT APPROVAL DATE P MIT EXPIRAT/IOONN DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIED`-ACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY