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STATE OF CALIFORNV WATER RESOURCES CONTR OARD FORM `B': UNDE GROUND STORAGE TANK PRO RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT RyCHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK O ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT _❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: (- W J .IM-C� FARM TANK-YES❑ NO N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 00 A. OWNERS TANK ID# � w B. MANUFACTURED BY: (fl C. YEAR INSTALLED D. TANK CAPACITY INGALLDNS: �d 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 UN YLEADED ❑2 LEADED e'rDIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑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.# A C.A.S.#- 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A.TYPE OF. ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM r 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER I TANK 1 STEEL/IRON ❑2 STAINLESS STEEL E]3 FIBERGLASS E] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑81 OR METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXY UNING ❑4 PHENOLIC UNING LINING ❑5 GLASSUNING UNLINED ❑95 UNKNOWN ,•- ❑ IS LINING MATERIAL COMPATIBLEWITH IDD%METHANOL? ❑YES ❑ NO �JIOTHER V✓1w D. CORROSION ❑ I POLYEfHLENEWRAP ❑2 TARORASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE gf�'95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATkON CIRCLE A FABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A 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(UA 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 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL V95 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. f / P S / VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 1/ P PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DAT LAST USED(MO/YR) Z. ESTIM TED QUANTITY OF 3. W TANK FILLED WITH �I� A PO AAC+V GALLONS RE REMAINING IN I ATERIAL? YES E NO 1��`�' THIS FORM AAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 6 10 11 jfl6 b 6 CURRENT LOCAL AGENCY FACT ITY ID# APPROVED BY NAME PHONE#WITH AREA CODE rL 8 -2,0PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE / CHECK# PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY. FORM B(6-29-SB) THIS FORM MUST BE ACCOMPANIED A FACILITY/SITE APPLICATION, FORM `A',UNLESS A MMRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY -