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+ST%TE OF CALIFORN' WATER RESOURCES CONT BOARD ) S �FORM 'B': UNDERGROUND STORAGE TANK PRI GRAM TANK TANK PERMIT APPLICATION INFORMATION M COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z ` oa MARK ONLY G-T"NEWPERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 10 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: Ala& FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY w A. OWNERS TANK IDN B. MANUFACTURED BY W C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Modo D� II. TANK CO TENS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. ❑ 1 UNLEADED ❑ 2 LEADED DIESEL F-] 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL E]6 AVIATION GAS 5j,❑ 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 HAZARDOUS SUBSTANCE STORED 8,C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A. TYPE OF ❑jDDUBUE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER rn 1 STEELARON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑S 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYO LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING Q 6 UNUNED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH L00%METHANOL? RrYES ❑ NO E-]99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP Ff2 TAR OR ASPHALT ❑ 3 VINYLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORM A ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A te 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A 191 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 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL 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. PD1 VISUALCHECK P 2 INVENTORY RECONCILIATION P S 3VAD6SEWELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P PRECISION TESTINGVS 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATEF DATE LAST E ( /YR) 2. ESTIMATED OU NTITY OF 3.WAS T NK FILLED WITH I/ VSUBSTANC MINING IN�- 17/MERIAL? E]YES=ENO Q /( GALLONS SFORM HAS BEEN UNDER PENALTY OFPERJURY, AND TO THE BEST OF MY KNOW EDGE, IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURR MILLOCAL AGENCY FACILITY ID# AP! O ED Y NAME PHONE#WITH AREA CODE 9!9 PERMIT NUMBER PERMIT APP OV DTE PERMIT EXPIRATION DATE CK# PERMIT AMOUNT U HECRCHARGE AMT. PEE CODE EIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA HAS BEEN FILED , DATA PROCESSING COPY