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STATE OF CALIFORN! WATER RESOURCES CONTRBOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. (az IG MARK ONLY 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CL SURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: N FARM TANK-YES[:1NOtqA 00 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN- SO SPECIFY 00 A. OWNERS TANK 0N7B. MANUFACTURED BY: �� N C. YEAR INSTALLED `I ID. TANK CAPACITY IN GALLONS: 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 02 P OLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED E] 3 DIESEL ❑3 CHEMICAL PRODUCT 401L PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OFI HAZARDOUS SUBSTANCE STORED&C.A.S.N VD I C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,&D A. TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM Er2 SINGLE LLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER El 1 STEELIIRON ❑2 STAINLESSSTEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑ B 100%METHANOLOOMPATIBLEFRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GMUNING UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IDO%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAOR ASPHALT ❑ 3 ViNYLWAAP ❑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 A 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER 8,CONSTRUCTION ASINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A 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 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.o P 1 VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P86 PRECISION TESTING P 8 7 PRESSURETESTING P S 91 NONE P 8 95 UNKNOWN P 8 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 ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID R TANK ID# CURRENT L CAL AGENCY FACILITY IDN APPROVED BY NAME PHONE p WITH AREA CODE U PERMIT NUMBER PERMITAPPROVALDATE PERMIT kXPIRAYION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECFIPT� BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIEDWA FACILITY/SITE APPLICATION, FORM'A',UNLESS A ENT FORMA' HAS BEEN FILED DATA PROCESSING COPY .