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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD °.`•• FORM B': ..ADERGROUND STORAGE TAN,.,,)ROGRAM TANK TANK PERMIT APPLICATION INFORMATION ` COMPLETE A SEPARATE FORM WITH THE FOLLOWING! FORMATION FOR EACH TANK. �+ MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TAN ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED / -y A FACILITY/SITE NAME WHERE TANK IS INSTALLED: G' FARM TANK-YES❑ NO FIT I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# D B. MANUFACTURED BY: z� �. C. YEAR INSTALLED D.TANK CAPACITY IN GALLONS: L 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 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS �+ ❑3 CHEMICAL PRODUCT ❑4 OIL ❑ 1 PRODUCT ❑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 6 C.A.S.# C.A.S.If: A '. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C.A D A.TYPE OFk!2yZKLE E WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC r B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ' MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ i RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 NOLIC LINING C.IN N IOR ❑5 GLASS LINING E]6 UNLINED MOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP n'lTAR OR ASPHALT El VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC r PROTECTION E]5 CATHODIC PROTECTION (r�Jy 91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMA ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER • B.CONSTRUCTION A JUSINGLE 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 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 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. oq n P 1 VISUAL CHECK 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS ,J 1` P 8 6 PRECISION TESTIN P 8 7 PRESSURE TESTING P 8 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. ESTIMATEP QUANTITY OF 3.WAS 7PNK FILLED WITH `~ SUBST%E EMAINING IN N TERIAL? 0 YES ❑NO GALLONS _ THIS F RM HAS BEEN COMPLETED UNDER PENALTY F PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE r LOCAL AGENCY USE ONLY EPERMITNUMBER JURISDICTION# AGENCY# FACILITY ID# TANK ID# aD �A ENCY FACILITY ID N APPRO�2ME HONE N WITH AREA CODE PERMIT APPROVAL DATE P MIT EXP ATION DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODERECEIPT# BY: FORM B(e-29-w) THIS FORM MUST BE ACCOMPANIED d A FACILITY/SITE APPLICATION, FORM'A',UNLESS A**.wRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY ,:..�?.:• _ --_____ _. _.mss+.. •._ •�a.r. r..__- -