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STATE OF CALIFORNIfS WATER RESOURCES CONTR DARD FORM `B': UNDERGROUND STORAGE TANK PRQD AM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 4 > '' !C7 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT en�5'CHANGE OF INFORMATION ❑ 7 PERMANENTLYC K ONE ITEM ® 2 INTERIM PERMIT F--] 4 AMENDED PERMIT 1:16 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: �( FARM TANK-YE5❑ NO N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C, YEAR INSTALLED D. TANK CAPACITY IN GALLONS: �r II. 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. ❑ I UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT CJ 4 OIL 0 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN L,�2 WASTE ❑ 7 METHANOL �9 OTHER(DESCRIBE iN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D k TYPE OF ❑ I DOUBLE WALLED ❑ 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 WIFIBERGLASSREINFORCED PLASTIC B.TAN!( F-] 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR F-] 1 RUBBER LINED ❑2 ALKYD LINING F-] 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING el UNLINED ❑95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH ICO%METHANOL? ❑YES ❑ NO �90THER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODICPROTE71ON ❑91 NONE �?95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVE GROUND, U IFUNDE UND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 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 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 1 OD%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL UrS UNKNOWN A U 99 OTHER „ LEAK DETECTION SYSTEM 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 5 4 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1, ESTIMATED D TE LAST USED(MO/YR) 2. ESTIMATED UANTiTY OF 3.WAS TA FILLED WITH SUBST N GALLONS //��AINING IN IN SIAL? ElYES ❑ NO THIS FOR HAS BEEN COMPLETED UNDER PENALTY O PERJURY,AND TO THE:BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT"S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY [PERMIT OUNTY# JURISDICTION# AGENCY# [E6 FACILITY ID# TANK ID# Tl I I E PW I f lo "(v CURRENT LOCAL A ENGY FACILITY iTY ID# APD BY PHONE#WITH AREA CODE NUMBER PERMIT APPROVAL DATE PERM EXPIRATION D TE N PERMIT AMOUNT SURCHARGE AMT. PEE CODE RECEIPT# BY: FOAM B(6-29-Ba) THIS FORM MUST BE ACCOMPANI O BY A FACILITY/SITE APPLICATION, FO R M 'A',UNLE;SWVRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY