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STATE OF CALIFORN WATER RESOURCES CONTRJWOARD" FORM 'B': UND GROUND STORAGE TANK PRRAM TANKTANK PERMIT APPLICATION INFORMATION COM ETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED T ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED D FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO IV I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: o or 1eir-T) F"L C. YEAR INSTALLED z IFD. TANK CAPACITY IN GALLONS: AO Q II. TANK TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,C PLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM L B. C 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL F-] 3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑ 4 GASAHOL 5 JET FUEL ❑ 6 AVIATION GAS ❑ 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&C.A.S.# C.A.S.#: III. TANK CONSTRU TION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS /4STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE El6 POLYVINYLCHLORIDE F-] 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN E] 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING DET'3-EPDXY LINING F-14 PHENOLIC LINING LINING ❑5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑ NO ❑ 99 OTH D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC,, PROTECTION 5 CATHODIC PROTECTION 91 NONE 95 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 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A 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) AU 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 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 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS l[ P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER 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? 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# I E[ I Loi131 / � D6l ! CURRENT LOCAL AGENCY FACILITY ID# APP OV BY M PHONE#WITH AREA CODE 35 �J PERMIT NUMBER PERMIT APPROVA PERMIT Ex;rON/D7�, CHECK# PERMIT AMOUNT SURCHAR AMT. FEE CODE R CEIPT# 7-T BY: FORM B(6-29-68) THIS FORM MUST BE ACCOMPANIEA FACILITY/SITE APPLICATION, FORM `A',UNLESS A'WrnRFNT FORMA' HAS BEEN FILED DATA PROCESSING-COPY�'