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STATE OF CALIFORN14b WATER RESOURCES CONTROMPARD FORM 'B': UNDE ROUND STORAGE TANK PRO AM w TANK PERMIT APPLICATION INFORMATION E A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z TANK COMo MARK ONLY 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY LOS NK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVE T CJI) FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES NO CA) I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: GI C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: DOO II. TANK 22NTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,'OOMPLETE ITEM 1 UNLEADED LEADED ❑3 DIESEL A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. F-] 3 CHEMICAL PRODUCT ❑4 OIL 0-1-PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL [:] 6 AVIATION GAS ❑ 5 HAZARDOUS ❑BO EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: `y HAZARDOUS SUBSTANCE STORED&C.A.S.q 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX M B,C,8 D A.TYPE OF I LE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN ❑ SYSTEM 2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER e/1 STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 6100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ IO GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER ❑ 1 RUBBERUNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR ❑5 GLASS UNING ©6 UNLINED ❑�y95 UNKNOWN LL LINING ❑ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO Fvr9g OTHER l Aa 2 0.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE t4-UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFAS InGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION 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 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEELARON 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 GALVANIZEDSTEEL 95 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 7 P 1 �IONTE P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS f✓- S IN S 7 PRESSURE TE STING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATE DATE LAST USED(MO/YR) 2. ESTIMATED OUAN ITY OF 3.WAS TA KFILLED WITH SUBSTANC RE 14GALLONS /\/0 IN IN ) RIAL? E]YES ❑ NO /, THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# [Z� EjEv I as 161l EAGENCY FACILITY ID# APPROVED BY N E PHONE#WITH AREA CODE iz PERMIT APPROVAL D TE PERMIT EXPIRATION DATE PERMIT AMOUNT SURCHARGEA74 . FEE CODE RECEIPT BY: JFORMB(6-29-88) THIS FORM MUST BE ACCOMPANI Y A FACILITY/SITE APPLICATION, FORM `A',UNLESS RRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY