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STATE OF CALIFORN16 WATER RESOURCES CONTR OARD FORM 'B': LAND GROUND STORAGE TANK PR RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ,_� Z MARK ONLY F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED NK I® ONE ITEM [-]2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED / FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES NO CA) 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY W A. OWNERS TANK ID# B. MANUFACTURED BY: V L 00 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK PONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED OMPLETE ITEM D. A_ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B C. 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL F-13 CHEMICAL PRODUCT ❑ 4 OIL [lil/lPRODUCT ❑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 OF L HAZARDOUS SUBSTANCE STORED&C.A.S.# (J Jl C A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A.TYPE OF ❑ OUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEELLRON ❑2 STAINLESS STEEL ❑ 3F18ERGLSS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYDUNING 3 EPDXY UNING4 NOLICUNING LINING ❑5 GLASS LINING ❑6 UNLINED 95 NKNOWN �1 ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES E] NO aoTHER V'•� D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3 INYLWRAP F-14 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE LV 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 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 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A6 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. Q` S 1VISUAL CHECK P S 21 NVENTORV RECONCILIATION P S 3VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS J P 8 6 PRECISION TESTING S ] PRESSURE TE STING P S 91 NONE P 8 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 D NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE REST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(POINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# hof EFORmB(629-88) AGENCY FA ILI„TY-ID# APPROVED BY NAME PHONE p WITH AREA CODE PERMITAPP VALD TE P RMIT EXPIRATION DATE PER AMOUNT URCHARGE AMT. FEE CODE CEIPT p Byo HIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED _ DATA PROCESSING COPY