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STATE OF CALIFORU WATER RESOURCES CONT BOARD FORM 'B': UN RGROUND STORAGE TANK PGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ONE ITEM ❑ Z PERMANENTLY CLOSEgTANK ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE [ BJ A K REMOVED (FACILITY/SITE NAME WHERE TANK IS INSTALLEDvFARMTANK-YES❑ NOjs I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY CTT LA. OWNERS TANK ID# ) 00 B. MANUFACTURED BY:YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK f3 cyu CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. EMOTOR CLE FUEL F-1 2 PETROLEUM 13 C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL 5 5ODUCT ❑ 4 OIL 1 PRODUCT ❑4 CASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS An PKA01 iD HICLE FUELHAZARDOUS ❑ENTER NAME ❑ 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ gg OTHER(DESCRIBE IN ITEM DBELOW) TANCE STORED 8 C.A.S.# C.A.S.a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,6 D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER B.TANK ❑ I STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR El RUBBER LINED E] ❑ 2 ALKYD LINING 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED 95 UNKNOWN ,A ,11 E] ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑ YES ❑ NO 99 OTHER I A I�/I,— D.CORROSION ❑ 1 POLYETHLENE WRAP TAR OR ASPHALT ❑ 3 VINYL WflAP ❑4 FIBEflGLASS REINFORCED PLASTIC PROTECTION E] 5 CATHODIC PROTECTION �I NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMAILON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 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 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL 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 9 GALVANIZED STEEL A U05 UNKNOWN A U 99 OTHER A U B 100%METHANOL COMPATIBLE FRP V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. PIS 1 VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 3 5 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 DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH -_, SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES E:] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY F CILITY ID �O� / APPROV DBY NAME rr PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT E IRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE CEIPTN BY: FORM B(62988) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY