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STATELI WATER RESOURCES CONTROpARD FORM `B' UNDER ROUND STORAGE TANK PRO AM TANKTANK PERMIT APPLICATION INFORM TION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INF' TION FOR EACH TANK. ^" 1 MARK ONLY ❑1 NEW PERMIT F-�3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ®2 INTERIM PERMIT ®4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED zkl' FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES Q NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# B.MANUFACTURED BY, L� C.YEAR INSTALLED / D. TANK CAPACITYIN GALLONS: VV(f II. TANK C TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM. A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. F� 1 UNLEADED ® 2 LEADED IESEL 3 CHEMICAL PRODUCT r 4 OIL 1 PRODUCT ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS 5 HAZARDOUS 80 EMPTY [:]95UNKNOWN 2 WASTE 7 METHANOL [—] 99 OTHER(DESCRIBE 1N ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: Ill. TANK CONSTRUCTJON MARK ONE ITEM ONLY IN Box A,B,C,& A.TYPE OF ❑"1 DOUBLE WALLED F-]3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM ❑2 SING LLED ❑4 SECONDARY CONTAINMENT ❑'99 OTHER STEEL/IRON 2 STAINLESS STEEL ®3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ®5 CONCRETE ❑6 POLYVINYL CHLORIDE ®7 ALUMINUM 3 10096 METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ® 1 RUBBER LINED ®2 ALKYD LINING ❑3 EPDXY LINING ❑4 P LIC LINING LINING ❑5 GLASS LINING ®6'UNLINED 95 UNKNOWN ® IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ®YES NO 99 OTHER D.CORROSION' ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 V L WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC'PROTECTION 0 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 U5 UNKNOWN A U 99 OTHER B.CONSTRU 'ON A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A CLA5 UNKNOWN A U 99 OTHER A U 1 STEELPRON A U 2 STAINLESS STEEL 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 CLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 5 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 1 VISUAL -HECK 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS A S PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PER A TLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USE YA) 2.'ESTIMATED QUANTITY OF 3.WAS TANK PILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E]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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID#> TANK ID=# 731- CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE P MIT EXPIRAXON DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT'# BY: FORM B'(6-29-88) THIS FORM MUST BE ACCOMPANNIM FACILITY/SITE APPLICATION, FOR `A',UNLESS' ENT FORMA' NAS BEEN FILED PROCESSINGbATA Y