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STATE OF CALIFORNI WATER RESOURCES CONTROARDf FORM `B': UNDER ROUND STORAGE TANK PRO AM _ . TANK PERMIT APPLICATION INFORMATION " .q TANK GF COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ©NEW PERMIT ❑ 3 RENEWAL,PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSETANK ONE ITEM ❑ 2 INTERIM PERMIT F--] 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED; / FARM TANK-YE5 NO CSI I. TANK 'DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—$0 SPE IFY Q A. OWNERS TANK ID P B. MANUFACTURED BY. C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. e-� MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADS➢ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS F-180 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&G.A.S.# C.A.S.N: -ZIA- III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ?2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER I e`J ' STEELIIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL [795 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED F-12 ALKYD LINING F-] 3 EPDXY LINING ❑4 PHENOLIC LINING LINING C. F—] 5 GLASS LINING UNLINED ❑ 95 UNKNOWN , LINING 0 IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO P/99OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAO OR ASPHALT ❑ 3 INYL WRAP [:] 4 FIBERGLASS REINFORCED PLASTIC 'PROTECTION ❑ 5 CATHODIC PROTECTION E]91 NONE 95 UNKNOWN El 99 OTHER IV. PIPING INFORMATION CIRCLE A IF AB GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A SUCTION A U PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION U 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 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) 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 a 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL Ag 95 UNKNOWN A U 99 OTHER EAK DETECTION STEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. p VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS JS PRECISION TESTIN 5 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1,:ST41MATEDATE LAST USED(MOIYR) 2. ESTPMATED fl ANTITY OP F3.�WWAS TAN FILLED WITHSUBSTA E ANTITNG IN E M T RIAL? ❑YE5 ❑ NO 7GALLONSTRM HAS BEEN COMPLETED UNDER PENALTY OF ERJURY,AND TO THE BEST OF MYOWLE GE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# � 61c) 101 CURRENT LOCAL AGENCY FACILITY ID# APPROY D NAME PHONE#WITH AREA CODE A) ` 1 -r rPERMIT NUMBER PERMIT APPRO L D/A PERMIT XPIRATION DATE 2-I a �— CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: { FORM B(6-29-as) THIS FORM MUST BE ACCOMPANIED h► FACILITYISITE APPLICATION, FORM `A',UNLESS A C NT FORMA' HAS BEEN FILED /\/) DATA PROCESSING COPY