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STATE OF CALIFORak WATER RESOURCES CONTwL BOARD FORM 'B': U RGROUND STORAGE TANK P GRAM "° TANKTANK PERMIT APPLICATION INFORMATION ° .o COMPLETEA SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ,L 1� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT G .,CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4rrAMENDED PERMIT ❑ fi TEMPORARY TANK CLOSURE ❑8 TANK REMOVED4N9--w FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1555- FARM TANK-YES❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY co A. OWNERS TANK ID# ..Z B. MANUFACTURED BY: lL FV C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Bd 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 ROLEUM V2WA C. ❑ 1 UNLEADED E] 2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT 4 OIL CT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS E] 5 HAZARDOUS ❑60 EMPTY ❑95 UNKNOWN ❑ 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.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,AD A.TYPE OF ❑ 1 9WBUE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM pts! 51 LE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER STEELARON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CIAO W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 1 ALUMINUM ❑B 1D0%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBEfl LINED ❑2 AIKYDUNING ❑ 3 EPDXY LINING4 FOLIC LINING C. INTERIOR Ln— LINING ❑5 GLASS LINING ❑6 UNLINED 95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TAO OR ASPHALT ❑ 3 LWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U WALLED A U 2 DOUBLE WALLED A U 3 LINEOTRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A i 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 8 100%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 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S I PRESSURE TESTING P 8 91 NONE P - 95 UNKN 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? E]GALLONS ❑ 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 IDM TANK ID# 3 = = I I I / CURRENT LOCAL AGENqKFACILI�� APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT 'URCHARGE AMT. FEE CODE �EIPTN BY: /� WI FORM B(6-29-eB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FOR M 'A',UNLESS A CURRENT FO�EEN FILED /