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STATE OF CALIFORN& WATER RESOURCES CONTRABOARD FORM `B': UND GROUND STORAGE TANK PR RAM ' m'= TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z MARK ONLY F-] 1 NEW PERMIT F--] 3 RENEWAL PERMIT E]5 CHANGE OF INFORMATION [:] 7 PERMANENTLY CLOSED ' 10 ONE ITEM❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT L]6 TEMPORARY TANK CLOSURE �ANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: b N. FARM TANK-YES❑ NO (A) I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N 00 A. OWNERSTANKIO# B. MANUFACTUREDBY: C. YEARINSTALLED L444*1-' 1 D. TANK CAPACITY IN GALLONS: Q It. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ i MOTOR VEHICLE FUEL ❑ 2 P ROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT 4 OIL 2T,'PRODUCT ❑4 GASAHOLFUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 60 EMPTY ❑95 UNKNOWN ❑2 WABTE ❑7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAMEOF p HAZARDOUS SUBSTANCE STORED&CA.S.# (�[K � C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BO%A,B,C,&D A.TYPE OF ❑ 1 DOUBLEWALIED ❑ 3 SINGLE WALLED WITH EXTERIOR LINEA ❑ 95 UNKNOWN SYSTEM dSINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER �STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3FIBERGLASS ❑ 4STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑ 6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FAP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBEAUNED ❑ 2 WD LINING F-] 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING 6 UNLINED ❑ NKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 99OTHEA D. CORROSION ❑ I POLYETHLENEWRAP 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 W91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 12 9/ 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 Q 91 NONE Naue C. MATERIAL A US ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%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. P S 1VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING 8 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMA ED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3.W S TANK FILLED WITH / 06 SUBSTANC E INING IN GALLONS /�@RT MATERIAL? F]YES ❑ NO W THI§FORM HAS BEEN COMPLETED UNDER PENALTY OF ERJURY,AND TO THE BEST OF MY KN WLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# b 1 6 12J -5 19 1-3 1 1010 10 CURRENT LOCAL AGENCY FAGI ID# APPROVED BVM PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT PIRATION DATE ICNECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-86) THIS FORM MUST BE ACCOMPAMrD BY A FA Cl- APPLICATION, FORM 'A',UNLESVIITURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY