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STATE OF CALIFORN* WATER RESOURCES CONTR IOARD FORM `B': UNDERGROUND STORAGE TANK PR RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY OWS D A K ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED wo FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YE5❑ NO z 10 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# 6 7 B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. Ln A. Vi MOTOR VEHICLE FUEL 2 PETROLEUM B. C. UNLEADED ❑ 2 LEADED ❑ 3 DIESEL m ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL a?l PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL E] 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.4 G.A.S.#: 'dj /A xill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM V2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER V, STEELIIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASSREINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE 10 GALVANIZED STEEL [::] 95 UNKNOWN E] 99 OTHER 1 RUBBER LINED ❑2 ALKYD LINING F-13 EPDXY LINING 4 PHENOLIC LINING C. INTERIOR ❑ LINING 5 GLASS LINING �i UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:] 5 CATHODIC PROTECTION 91 NONE ❑95 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 U 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 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PUC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A /U�6 CONCRETE A U T STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FHP A!J A U 9 GALVANIZED STEEL A 95 UNKNOWN A U 99 OTHER V. EAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTROffONIT�DRP �5GORTO' ND WATER MONITORING WELLS P 6 PRECISION TESTING P S 4, PRESSUAETESTING P S 91 NONE P S 95 UNKNOER r-.ter' VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE ET4HAS E LAST USED(MO/YR) 2. ESTiMAT D UAN7ITY OF 3.WAS TAN FILLED WITH SUBS MAINING IN INE RIAL? ❑YES NO GALLONS TIBEEN COMPLETED CINDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUrnNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# El It) In r, jr, I -k I`- I lo CURRENT LOCAL AGE14CY FACILITY ID# APPROVE NAM PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PE MIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(3-7-m) THIS FORM MUST BE ACCOMPAN A FACILMISITE APPLICATION, FORM 'A',UNLES .. RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY