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STATE OF CALIFORNIi WATER RESOURCES CONTRO OARD FORM 'B': UNDERGROUND STORAGE TANK - I AM TANKTANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING IN RMATION FOR EACH TANK. Z :O MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT E4KCHVANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED 6 N FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO W 00 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO CIFY A. OWNERS TANK ID# (J B. MANUFACTURED BY: (J C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: G O II. TANK CO ENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COM ETE ITEM D. A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. UNLEADED ❑ 2 LEADED 3 DIESEL B. ❑3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 60 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF J HAZARDOUS SUBSTANCE STORED&C.A.S.# 10;6L C.A.S.#: A III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A A TYPE OF ❑ 1000 ALLED F-]3 SINGLEWALLEOWITH EXTERIOR LINER 95 UNKNOWN SYSTEM IMG WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 RBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE 7 ALUMINUM ❑ B 10096 METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE ❑ 10 GALVANIZED STEEL F—] 95 UNKNOWN ❑99 OTHER ❑ 1 RUBBERUNED ❑2 ALKYD LINING ❑3 EPDXYLINING ❑4 PHEN LIC UNING C. INTERIOR 5 GLASS LINING ❑6 UNLINED UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER 0. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TA ASPHALT F-]3 VINYL WRAP ❑4 RBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 1 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(42PRESSURE 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 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 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 A 5 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 VISUALCHECK �S 21NVENTORYRECONCILIATION P S 3VADOSE WELLS P S 4ELECTRONIC MONITOR P S 5GROUND WATER MONITORING WELLS p PRECISION TESTING P S 7 PflESSURE TESTING P S 91 NONE P S 9S UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST US DMO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS EEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# o CURRENT LOCAL ACETIFY FACILITY ID1,N APPROVED BY N E PHONE N WITH AREA CODE C///� /v PERMIT NUMBER PERMIT APPROVAL DATE PER EXPIRATION DATE CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODEECEIPT N BY: FORM B(6-29-fie) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA HAS BEEN FILED DATA PROCESSING COPY