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STATE OF CALIFORP* WATER RESOURCES CONT( BOARD aF FORM `B': UNDERGROUND STORAGE TANK PROGRAM a TANK TANK (PERMIT APPLICATION INFORMATION ° COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT �5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED ©l FACILITY/SITE NAME WHERE TANK IS INSTALLED: 2,LYL(/ iV FARM TANK-YES❑ NO I, TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED Ll C D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. ❑ 1 UNLEADED E] 2 LEADED F:] 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL Ell PRODUCT ❑ 4 GASAHOL 1'5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 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&C.A.S.# C.A.S.#: V/A xIl I. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM( R 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER F-] I STEELIIRON F-] 2 STAINLESS STEEL �3 FIBERGLASS E] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL F-] 5 CONCRETE ❑6 POLYVINYLCHLORIDE F-] 7 ALUMINUM E] 8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR F-11 RUBBER LINED ❑ 2 ALKYD LINING F-] 3 EPDXY LINING ❑4 PHENOLIC LINING LINING 0'5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D..CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TARORASPHALT F-13 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:]5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORM ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION AU 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FIBEHGLASSPIPE 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 AU 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. yF � P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION 5 3 VAOOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS fw P S 6 PRECISION TESTING P S 7 PRESSURETESTING PXS>l NONE P S 95 UNKNOWN P S 99 CTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE ST USED(MO/YR) 2. ESTIMATED C#ANTITY OF 3. WA TANK FILLED WITH SUBST E AINING IN MATERIAL? E]YES ❑ NO GALLONS 7H1S FORM ,S BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO LEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# FIF3 Loa TE54 CURRENT CAL AGENCY FACILITY I/D�M, APP O NAME � RHONE#WITH AREA CODE G 6A 44 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXP( ATION DATE (� CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: alk \V J FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FO R M 'A',U NLESIIFMRENT FORM`A' HAS BEEN FILED DATA PROC'1=SS;ING COPY