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STATE OF CALIFORNID WATER RESOURCES CONTR�OARD FORM `B': UNDERGROUND STORAGE TANK PRGGRAM TANK PERMIT APPLICATION INFORMATION TANK -°< COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ZO MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM 2INTERIMPERMIT F-1 4 AMENDEDPERMIT 6 TEMPORARY TANK CLOSURE VLB TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARMTANK-YES[ NO C.A� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CD A. OWNERS TANK IDN S. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 2 IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL F-1 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT ❑4 OIL F--] 1 PRODUCT ❑ 4 GASAHOL 5 JET FUEL 6 AVIATION GAS 5 HAZARDOUS ❑ 80 EMPTY [:] 95 UNKNOWN 2 WASTE 7 METHANOL D 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A. TYPE OF ❑ I DOUBLEWALLEO ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM [:)2 SINGLE WALLED F-1 4 SECONDARY CONTAINMENT 99 OTHER ❑ 1 STEEUIRON ❑ 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK F7 CONCRETE F�6 POLYVINYLCHLORIDE 7 ALUMINUM 8100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE 0 10 GALVANIZED STEEL D 95 UNKNOWN 99 OTHER 1 RUBBER LINED ❑ 2AUCYO LINING F-] 3 EPDXY LINING 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING �6 UNLINED 95 UNKNOWN LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL7 YES E NO 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP 2 TARORASPHALT 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLAST IC PROTECTION 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN D 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE 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 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 B 106%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 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 I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? DYES D 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# FTE[= I I I I I CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMR AMOUNT SURCHARGE AMT. FEE CODERECEIPT k BY: I FOi*B(6-29-BB) THIS FORM MUST BE ACCOMPANIETIlY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A L RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY