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STATE`O "GAIAFOR WATER RESOURCES CONTF BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION ` - COMPLETE A SEPARATE FORM WITH THE FOLLOWI G INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY CD W A. OWNERS TANK ID# Q B. MANUFACTURED BY: zoff CD C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 1.7,1 Off II. TANK ONTENTS IF(A-1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. V1 MOTOR VEHICLE FUEL E:] 2 PETROLEUM B. C• [::] l UNLEADED �EADED �,3 DIESEL 3 CHEMICAL PRODUCT �4 OIL PRODUCT ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY 95 UNKNOWN 2 WASTE ❑ 7 METHANOL 99 OTHER(DESCRIBE IN.ITv1 D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF F--] 1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 0 2 SINGLE WALLED 4 SECONDARY CONTAINMENT [:]99 OTHER 1 STEEL/IRON 2 STAINLESS STEEL 3 FIBERGLASS F—]4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK r--ll 5 CONCRETE F-1 6 POLYVINYLCHLORIDE 7 ALUMINUM 610096 METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE El 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING HENOLIC LINING C.INTERIOR LINING ❑5 GLASS LINING 6 UNLINED ' 95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES [::] NO F-1 99 ER D.CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:] 5 CATHODIC PROTECTION 91 NONE 0 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE U / A.SYSTEM TYPE A U 1 SUCTION A PRESSURE AVITY A U 91 NONE A U1,45 UNKNOWN A U 99 OTHER .01 B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 P LWAtT A U 3 LINED TRENCH A U 91 NONE A U95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON t#"1 2-STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM AJIL-6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A( UJJ5 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. 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS \CiJ S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99sOTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/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&SIGNATURE) DATE LOCAL AGENCY USE ONLY P JURISDICTION# AGENCY# FACILITY ID# TANK ID# ET!7-111 1 -11 111 o To -T Tl AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT APPROVAL DATE PERMI XPIRATION DATEPERMIT AMOUNT URCHARGE AMT. FEE CODE ECEIPT# BY: FORM B(6-29- IS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY