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.. ,ti. f`.1..;iI! GS"r'w._^T's�F+-•'�RJ:'$�i"R��4�'' .. ' STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION = �° COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT OHANGE 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 L TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# ;-- B. MANUFACTURED BY: Pte* [ 1 C. YEAR INSTALLED + D. TANK CAPACITY IN GALLONS: I1. 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 ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ��ASTE ❑ 7 METHANOLTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF 15-11,Spy sem- l HAZARDOUS SUBSTANCE STORED&C.A.S.# CAS #, 5-0 ,le 4-q x111, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D 1,43 3Cj 1w A TYPE OF ❑ 1 DOUB E WALLED F-] 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM INGLEWALLED ❑ 4 SECONDARY CONTAINMENT 99 OTHER F—] I STEELMON ❑ 2 STAINLESSSTEEL F--] 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑ 6 POLYVINYLCHLORIDE F--] 7 ALUMINUM ❑8 100%METHANOL COMPATIB EFRP ❑9 BRONZE ❑ 10 GALVANIZEDSTEEL ❑ 95 UNKNOWN HER 14 k-1 F—] 1 RUBBER LINED ❑ 2 AL 9 ING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TA ASPHALT ❑ 3 VINYL WRAP [:]4 FIBERGLASS REINFORCED PLASTIC PROTECTION E] 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 2 PRESSURE A U 3 GRAVITY A ®99 OTHER B.CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U B 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 INVENTQRY RECONCELfAT1flN P 5 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S S GROUND WATER MONPTORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNpWA P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE).AST USED{ O/Y ) 2. ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH 167 GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES [:] NO THIS FORM HAS REA 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# 1c) I r cI �L-1 LO a CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE k WITH AREA CODE S U V�zlPERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(3-7-86) THIS FORM MUST BE ACCOMPANIES a A FACILITY/SITE APPLICATION, FORM 'A',UNLESSAZ RENT FORM W HAS BEEN FILED DATA PROCESSING COPY