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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM 4 'm TANK TANK PERMIT APPLICATION INFORMATION : a COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - "^ MARK ONLY �r NEW PERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL K 10 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE R TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: N W FARM TANK-YES❑ NO , V'I I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY l--) Q A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 'L o II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 ETI"PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL 6 AVIATION GAS 5 HAZARDOUS ❑ BO EMPTY ❑ 95:UNKNO:WN:[[:] 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIDE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# SCI C.A.S. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM O'SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEELPRON F-12 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F--] 5 CONCRETE F-] 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 13B%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 1G GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING F-] 3 EPDXY LINING E] 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING UNLINED ❑ 95 UNKNOWNS ❑ IS LINING MATERIAL COMPATIBLE WITH IW%METHANOL? ❑YES ❑ NO Eq<OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TARORASPHALT ❑3 VINYL WRAP El4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION E] 91 NONE IJ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 4 1 SUCTION A PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION 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 STEELIRON A U 2 STAINLESS STEEL 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 GALVANIZED STEEL k 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. r P S 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS r� P 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI, INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE ST USED(MO/YR) 2. ESTIMATED OU NTITY OF 3. WAS TANK ILLED WITH SUBS7A E M KING IN INER L? ❑YES ❑ NO GALLONS (/'`j THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF ERJURY,AND TO THE BEST OF MY KNOWLEDGF, 1S TRUE AND CORRECT: APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# I ET I I I(_5 1�, 167zl o I o CURRENT LOCAL AGENCY FACILITY ID N APPROVE BY A14E PHONE#WITH AREA CODE PERMIT NUMBER PER; APP OV L DATE PERMIT EXPIRATION DATE 1 � CHECK# PERMIT AMOUNT SURCHAR E AM FEE CODE RECEIPT N BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPNED BY A FACILITY/SITE APPLICATION, FORM `A',UNLE CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY