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STATE OF CALIFOR WATER RESOURCES CONTO BOARD 5' s FORM `B': UND RGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. -- MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7,PERMANENTLY CLO ONE ITEM ❑ 2 INTERIM PERMIT El AMENDED PERMIT El TEMPORARY TANK CLOSURE B TANK REMOVED © IV FARM TANK-YE5❑ NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: (1 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF'UNKNOWN-SO SPECIFY —4 A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D A. 1 MOTOR VEHICLE FUEL F-] 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT ❑ 4 OIL EV PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BD 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.N C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑ OUBLE WALLED F--] 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE F-] 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1 W%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ HENOLIC LINING C. INTERIOR I�I 5 GLASS LINING F-] 6 UNLINED 95 LINING UNKNOWN ' LJ ❑ IS LINING MATERIAL COMPATIBLE WITH IOA METHANOL? ❑YES ❑ NO X49 OTHER- D.CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT Y13 NYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:] 5 CATHODIC PROTECTION ❑ 91 NONE NKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A JY21 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 U UNKNOWN A U 99 OTHER A U 1 STEELIIRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 WRGLASS 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 1OD%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AU 5 UNKNOWN A U 99 OTHER V. LEAK DETECTIONYSTEM CIRCLE P FOR PRIMARY,CR S FCR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. fkE�:: UAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S I GROUND WATER MONITORING WELLS ECISION TESTING P S 7 PRESSOR@ TESTING P S 91 NONE P S 95 UNKNOWN P S 99 dTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1, ESTIMATED[DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF T3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑�NO GALLONS THIS FORM HAS BEEN 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# 0�1 CURRENT LOCAL AGENCY FACILIT o l f �/ ` APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT URGHARGE AMT. FEE CODE ECEIPT# BY: FORM B(6-29-95) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A VURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY