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STATE OF CALIFORO WATER RESOURCES CONT BOARD f FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION ° COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY Ff 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ® 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ®8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: l bo t4vm/ ` FARM TANK-YES❑ NO ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY �" �j GID' 10 A. OWNERS TANK ID# B. MANUFACTURED BY: U C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 00 w II. TAN_ K CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. Co A 1 MOTOR VEHICLE FUEL PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT 4 OIL lr2 RODUCT ❑ 4 GASAHOL 5 JET FUEL ❑ 8 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ASTE ❑ 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF � HAZARDOUS SUBSTANCE STORED 8 C.A.S.# C.A.S.k: XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑!,oXUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER E:] 1 STEELIIRON E] 2 STAINLESS STEEL F-] 3 FIBERGLASS E]4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-] 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE F-] 7 ALUMINUM E:] 8 100%METHANOL COMPATIBLE FRP � El BRONZE ❑ 10 GALVANIZED STEEL I v l%UNKNOWN ❑ 99 OTHER C. INTERIOR E-] 1 RUBBER LINED El2 ALKYD LINING ❑3 EPO)(Y LININGE:j�PHENOLIC LINING LINING ❑5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH loo%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ } POLYETHLENEWRAP ❑ 2 TAA ORASPHALTLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN E:] 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 A&/3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUMA 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL j 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. Bs 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS � 6 PRECISION TESTING P 5 7 PRESSURETESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE f. ESTIMATED DATE LAST USED(MOIYR) 2. ESTIMATED QUANTITY OF 3. WAS TANK KILLED WITH SUBSTANCE REMAINING IN INERT MATERIALS YES NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# hQL0 116 CURRENT LOCAL AGENCY FACILITY JD 0 APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE (/ PERMIT EXPIRATION DATE CHECK 0 PERMIT AMOUNT CHARGE AMT. FEE CODE RE IPT# BY: FORM B(3a-8s) THIS FORM MUST BE ACCOMPA AR APPLICATION, FORM `A',UNLESRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY