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STA I E OF CALIFORNI.4 WATER RESOURCES CONTROL 'DARD FORM 'B': UNDEAtROUND STORAGE TANK PROGRAM TANK 4 TANK PERMIT APPLICATION INFORMATION (oz COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT �� CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE [];� f�K REMOVED �C) L _ N FACIUTY/SITE NAME WHERE TANK IS INSTALLED: )( {lY` FARM TANK-YES❑ NO 4kb. I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY N A. OWNERS TANKIDK B. MANUFACTURED BY: V C.YEAR INSTALLED LL2: D. TANK CAPACITY IN GALLONS: (J 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 P LEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL F-13 CHEMICAL PRODUCT OIL ❑ 1 PRO ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑SO EMPTY ❑95 UNKNOWN _ .ASTE ❑7 METHANOL �HER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF 11 HAZARDOUS SUBSTANCE STORED&C.A.S.H 'I�'"C:� �-�-�I C.A._ 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑ 1 DW WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM LLKSING2AULED ❑4 SECONDARY CONTAINMENT ❑99 OTHER DII &BUIRON ❑2 STNNLESS STEEL ❑3 FIBERGLASS ❑451EELCLADWIFIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 8100%METHANOL COMPATIBLE FRP ILITEIIIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXY UNING ❑LINING LINING ❑5 GLASS LINING ❑6 UNLINED UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 1NN6 METHANOL? ❑YES ❑NO ❑99 OTHER 0. CORROSION ❑ I POLYETHLENEWRAP ❑2TAR OR ASPHALT ❑3VI ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION E] 91 NONE 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 U 3 GRAVITY A U 91 NONE A 47 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 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A CONCRETE A U 7 STEEL CLAD W/FRP A U 81DO%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING 91 NONE P S 95 UNKNOWN P 8 99 OTHER V . INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LASTUBED(MO/Y ) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH 0 // 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 S JURISDICTION* AGENCY M FACILITY ID N TANK ID* = r3 CURRENT LOCAL AGENCY FACILITY ID B APPROVED BY AME PHONE k WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PE MR EXPIR ON DATE CHECK* PERMITAMOUNT SURCHARGEAMT. FEE CODE EIPT* BY: V FORM B(6-29-86) THIS FORM MUST BE ACCOMPANIMP A FACILITY/SITE APPLICATION, FORM 'A',UNLESS rt6nRENT FORMAHAS BEEN FILED DATA PROCESSING COPY