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STATE OF ICALIFORNI WATER RESOURCES CONTRC ,BOARD b•' '^ FORM 'B':` ' "UNDERGROUND STORAGE TANK PROGRAM TANK �/ TANK PERMIT APPLICATION INFORMATION `�, : COMPLETE A SEPARATE FORM WITH THE FOLLOWING I RMATION FOR EACH TANK. MARK ONLY. i ` ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: , �jl/ /& FARM TANK-YES NO ❑ IV c:) I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-=SO SPECIFY Cd Co A. OWNERS TANK ID It S. MANUFACTURED BY: C.YEAR IN TALLED D. TANK CAPACITY IN GALLONS: i H. TAN ONTENTS IF(A-1),IS MARKED,COMPLETE ITEM C.IF(A.1),,15 NOT MARKED,COMPLETE ITEM D A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUMB. C. ❑ 1 UNLEADED 2 LEADED E]3 DIESEL ❑ 3 CHEMICAL PRODUCT E:] 4 OIL 1 PRODUCT ; ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL E]99 OTHER{DESCRIBE IN ITEM D,BELOW} D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.N ' C.A.S.N' III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,ak D I A.TYPE OF ❑`1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER EX95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT } ❑�99 OTHER ❑ 1 STEELPRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑�4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 6 1W%METHANOL COMPATIBLE FRP ILII MATERIAL. - ❑9 BRONZE ❑ 10 GALVANIZED STEEL [].95 UNKNOWN ❑C99 OTHER ❑ I RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXY LINING [:]14 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ❑ fSaNINGMATERIAL COMPATIBLE WITH 100%MOWOL? ❑YES ❑NO 0�99OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP D:4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑;99 OTHER i IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IFbNDERGROUND,BOTH IFAPPLICABLE A SYSTEM TYPE A U 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 DOUBLEWALLED. 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 STAINLESS STEEL' A U 3 POLYVINYL CHLORIDE IPVC) 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 4 V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK ' P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 ONKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED AMO/YR) 2. ESTIMATED QUANTITY OF l 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN ! INERT MATERIAL?GALLONS OYES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNO WLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE it LOCAL AGENCY USE ONLY COUNTY S JURISDICTION N AGENCY N FACILITY ID N TANK ID N CURRENT LOCAL AGENCY FACILITY ID APPROVED BY NAME ! PHONE k WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK/ PERMIT AMOUNT SURCHARGE AMT. FEE CODE - RECEIPT It BY:J FORM B(6.29-06) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS SEEN FILED