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STATE OF CALIFORNO WATER RESOURCES CONTROBOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM ` TANK TANK PERMIT APPLICATION INFORMATION ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWALPERMITCHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED !Z FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1'4 AA FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 A. OWNERS TANK ID# 0 -�2B. MANUFACTURED BY: C. YEAR INSTALLED G D. TANK CAPACITY IN GALLONS: W IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. --4 A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PET LEUM 8. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL c" ❑ 3 CHEMICAL PRODUCT OIL PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS J ❑5 HAZARDOUS [:] 80 EMPTY [-] 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL EZ;KOTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.If C.A.S.#: IV= y ,rill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ I DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM SNGLEWAUED ❑4 SECONDARYCONTAINMENT ❑99 OTHER ❑ 1 STEELIIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGlAS3 REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALU M ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBERUNED ❑ 2 ALKYD UNING ❑ 3 EPDXY LINING ❑ 4 PHENO CUNING LINING ❑5 GLASS LINING ❑6 UNLINEDNKNOWN ❑IS UNING MATERIAL COMPATIBLEWITH I00%METHANOL? ❑YES ❑NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2TAR OR ASPHALT ❑3 VI WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION E]91 NONE UNKNOWN ❑99 OTHER IV. PIPING I NFORMATn CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLI CABLE A.SYSTEM TYPE A UCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLEWALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 05 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FISERGLASSPIPE C. MATERIAL A U 5ALUMINUM A LL,6 CONCRETE A U 7STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A e)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 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 3VADOSEWELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 5 PRECISION TESTING P S 7 PRESSURETESTING 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 & GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? F]YES ❑ NO THIS FORM HAS BEE COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE i LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# V CURRENT LOCAL AGENCY FACILITY ID X � APPROVED BY NAME � IT PHONE X WITH AREA CODE PERMIT NUMBER PERMAPPROVAL D PER EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPTX BY: FORM B(3-7-68) THIS FORM MUST BE ACCOMPANIE f A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A MRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY