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STATE OF CALIFORNIA' WATER RESOURCES CONTROI OARD FORM 'B': UNDEIMROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - Z 70 MARK ONLYEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE >�o TANK REMOVED N FACILITY/SITE NAME WHERE TANK IS INSTALLED: vzr FARM TANK-YES❑ NOI 40b I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY W k OWNERS TANK IDR Lb 2 B. MANUFACTURED BY: C. YEAR INSTALLED q A 12- D. TANK CAPACITY IN GALLONS'. Q-z II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. WI MOTOR VEHICLE FUEL F-] 2 PETROLEUM B. C. ❑ 1 UNLEADED kr2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL 1 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 OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.R C.A.S.R: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A.TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLE WALLED ❑ 4 SEGONDARYCONTAINMENT El 99 OTHER 1 STEELIIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 1DD%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED MEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I NUBBERUNED ❑��2 ALKYD LINING F-13 EPDXY UNING ❑4 PHENOLIC LINING .ISL° LINING ❑5 GLASS LINING UNLINED ❑95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH IOD%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP D;;r2 TAR OR ASPHALT ❑3 VINYLWRAP ❑4 FIBERGLASS RENFORCED 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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A STEEL/IRON A U 2 STAINLESSBTEEL 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 STEELCLADW/FRP A U 8100%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 t VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 5 PRECISION TESTING P S 7 PRESSURE TESTING 08 91 NONE P 8 95 UNKNOWN P 8 W OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED IMO/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. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY �COOUN�TY P JURISDICTION R AGENCY# FACILITY ID M TANK ID k [ I o o h 5 z CURRENT LOCAL AGENCY FACILITY IDN [7!WE NAME �. PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DA PERMIT EXPIRATION DATE CHECK N7 I PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORV R I5 29 551 THIS FORM MUST BE ACCOMPANIEnY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORMA' HAS BEEN FILED _) DATA PROCESSING COPY