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STATE OF CALIFORNA WATER RESOURCES CONT BOARD FORM 'B': UND GROUND STORAGE TANK PRMRAM ' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 P MANENTLY CLOS D oa ONE ITEM ❑2 INTERIM PERMIT 1:14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED r� y FACILITY/SITE NAME WHERE TANK IS INSTALLED: ie-, �� FARM TANK-YES❑ NO 1 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C YEAR INSTALLED D. TANK CAPACITY IN GALLONS: I F.► 11. TANK gONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,C PLETE ITEM D. �I A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL F-] 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN F-12 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME F HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.# III. TANK CONSTRUCTION MARK ONE I M ONLY IN BOX A,B,C,B D A TYPE OF ❑ I DOUBLEWALLED ❑3 SINGI WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ 4 SECOND CONTAINMENT ❑99 OTHER ❑ I STEEL/IRON ❑2 STAINLESSS L ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYL CHL IDE ❑ 7 ALUMINUM ❑ 81M%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED ST ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING 3 EPOI(Y LINING ❑ 4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑ 6 UNLINED ❑95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%MFTHANOL? YES ❑ NO ❑ 99 OTHER 0.CORROSION ❑ i POLYETHLENE WRAP ❑2 TARORASPHALT ❑ VINYLWRAP ❑4 FIBERGLASS REI NFORCE OF PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑95 KNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDE GROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 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 INED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 P YVINYL CHLORIDE(PVC) A U 4 HBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 ST LCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OT R V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY, 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 EL TRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UN OWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO7YR) 2. ESTIMATED OUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO GALLO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# � C� CID o0 363 CURRENT LOC91tGENCY FACILI ID APPROVED BY NAME PHONE#WITH AREA CODE /IJ PERMIT APPROVAL DATEPERMIT EXPIRATION PERMIT NUMBER DATE 1 CHECKN PERMIT AMOUNT SURCHARGE AMT. FEE CODE CEIPTN BY: FORM 8(6-29-B8) THIS FORM MUST BE ACCOMPANIE Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED L DATA PROCESSING COPY