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OF STATE OF CALIFORN WATER RESOURCES cONTR OAR© A FORM `B': UND GROUND STORAGE TANK PRO AM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ` ONE ITEM Q 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT Q 8 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED ��'" cn FACILITY/SITE NAME WHERE TANK IS INSTALLED. P5151 FARM TANK-YES❑ NO r\.) LTJ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY w A. OWNERS TANK ID# B. MANUFACTURED BY: CD C. YEAR INSTALLED 0. TANK CAPACITY IN GALLONS: 11- TANK CONTENTS IF(A•1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM 0. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS 5 HAZARDOUS 80 EMPTY Q 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&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I OOUBLEWALLED ❑3 SINGLE WALLEO WITH EXTERIOR LINER 95 UNKNOWN SYSTEM F\72 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 91 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGLASSREINFORCED PLASTIC B.TANK ® MATERIAL 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE Q 7 ALUMINUM Q 8 100%METHANOL COMPATIBLE FRP Q 9 BRONZE Q 10 GALVANIZED STEEL Q 95 UNKNOWN Q 99 OTHER C. INTERIOR Q 1 RUBBER LINED Q 2 ALKYD LINING ❑ 3 EPDXY LINING Q 4 PHENOLIC LINING LINING ❑ 5 GLASSUNING 6 UNLINED Q 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 1 W%METHANOL? 0 YES ❑ NO Q 99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP Q 4 FIBERGLASS REINFORCED PLASTIC PROTECTION Q 5 CATHODIC PROTECTION 091 NONE Q 95 UNKNOWN Q 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPEU 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 U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINFOTR€NCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U STEELIIRON 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 A 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. ��wyJ p 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 g" P 5 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 LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? El YES Q NO THIS FORK?HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE 1 LOCAL AGENCY USE ONLY =COUNTY# JURISDICTION# AGENCY# LLFI-ACILITY ID# TANK ID# I- 1z1 1 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29.aa) THIS FORM MUST BE ACCOMPANIEM A FACILITYISITE APPLICATION, FO R M `A',UNLESS A RENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY