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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD , FORM B': "ERGROUND STORAGE TANK _IOGRAM m TANi( YANK PERMIT APPLICATION INF&MATION ° t COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. , 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 P ANENTLY CLOSED TANK MARK ONLY ❑ ONE ITEM 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED 617 ,1 Ln r FACILITY/SITE NAME WHERE TANK IS INSTALLED: I FARM TANK-YES❑ NO s 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY y B. MANUFACTURED BY: `f A. OWNERS TANK ID# 03 C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: ' II. TANK C NTENTS 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 El3 DIESEL El 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT if 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 ` A C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,8,C,&D s- ' A TYPE OF ❑ LE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN ~J SYSTEM 2 SINGLEWAUED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASSREINFORCED RAM B.TANKF-1 5 F-16 POLYVINYLCHLORIDE F-17 ALUMINUM 8 IW%METHANOL COMPATIBLE FRP ' MATERIAL ❑9 BRONZE El 10 GALVANIZEDSTEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 D LINING 3 EPDXY LINING ❑4 PHENOLIC LINING C.INTERIOR ❑5 GLASSUNING 6 UNLINED ❑95 UNK WN J LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO OTHER D.CORROSION ❑ i POLYEfHLENEWRAP Fl OAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION X91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION 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 U 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 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL AU�,,,S ALUMINUM A U 6 CONCRETE A U 7 STEEL CLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A�,%7'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 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DAT LAST USED(MO/YR) 2.ESTIMAT D QUANTITY OF 3.W TANK FILLED WITH REMAINING IN MATERIAL? ❑YES ❑NO fYw�l GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENAL OF PERJURY,AND TO THE BEST OF MY KN LEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# F7 I I v J CUR NT LOCAL AGENCY FACILITY IDN APPR V�Z NP E PHONE S WITH AREA CODE 13 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK/ ---j-PlERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT• DY: '. FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIED of A FACILITY/SITE APPLICATION, FORM'A',UNLESS A I:UARENT FORM W HAS BEEN FILED DATA PROCESSING COPY