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STATE OF CALIFORNIAJ WATER RESOURCES CONTR OAR FORM 'B'; o UNDE GROUND STORAGE TANK PRO RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. sae MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ONE ITEM ❑ ' PERMANEN4[:jNO ANK NTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOFACILITY/SITE NAME WHERE TANK IS INSTALLED• r & ([,I" fl, / FARM TANK-YE I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY '— A. OWNERS TANK ID p C] B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. 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 El CHEWCAL PRODUCT ❑ 4 OIL I'S ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS HAZARDOUS ❑ 8D EMPTY ❑ 95 UNKNOWN Lr 1 "WASTE ❑ 7 METHANOL ❑ 99 OTHER(QESCRlBE fN ITEM Q.BELOW} D. T NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.If C.A.S. x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,S D A. TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER B. TANK 1:1 1 STEEL/IRON ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IN%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 PCLYLTHLENF WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 RBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE F.C;;rG5 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 A LW GRAVITY A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 PC✓_YVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AU 95 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED.. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 5 98 NONE P S 95 UNKNOWN P 5 99 OTHE VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED GATE-LST USED(MOlYR) 2. ESTIMAT D QUANTITY OF 3. WAST FILLED WITH S RS EMAINING IN IN T T L7 ❑YES ❑ NO GALLONS THIS FORM H S BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNO WLED E, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY - :T-1-1 COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# Lo CURRENT LOCAL AGENCY FACILITY ID# APPRO E0. ME PHONE#WITH AREA CODE 11 L P RMIT NUMBER PER IT PP OVAL DAT PE MIT EXPIRATION DATE CHECK# PERMIT AMOUNT S E FEE CODE RECEIPT# BY: FORM B(3-7-BB) THIS FORM MUST BE ACCOMPANIL—u Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS NERRIIENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY