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STATE OF CALIFORNIA- WATER RESOURCES CONTROL,, ARD FORM 'B': UNDEF*ROUND STORAGE TANK PRO AM ,=6a TANK PERMIT APPLICATION INFORMATION �° ' 3 TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. — Z 10 NEW PERMIT F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CL MARK ONLY ONE ITEM [:] 2 INTERIM PERMIT F—] 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED !/ - CA) FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO w I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY � A. OWNERS TANK ID% Li B. MANUFACTURED BY: C. YEAR INSTALLED U D. TANK CAPACITY IN GALLONS: U 0000 II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. Ell MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. Erl UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS I ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAMEOF I A HAZARDOUS SUBSTANCE STORED&CA.S.A A/1A C.A.S.R: k A Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,IS,C.A D A. TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM �2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEBUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC S.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ B 10D%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ I RUBBER UNED ❑2 A D LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING C. LINING INTERIOR ❑5 GLASS LINING UNLINED ❑ 95UNKNOWN (iT/L�� E] IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ai B90TNRI D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 ORASPHALT ❑3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION LZ91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF A11GROUND, U IF UNDERGROUND,BOTH IFAPPLICASLE 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 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A .LL 6 CONCRETE A U 7 STEELCLADW/FRP A U B 1f METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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 8 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS B 6 PRECISION TESTING P S ] PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED ANTITY OF 3.WAST NK FILLED WITH SUBSTA IINING TYOIN INE TERIAL? ❑YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY F JURISDICTION 8 AGENCY R FACILITY ID B TANK ID A © D 3 Z CURREN LOCAL AGENCY FA ILITY ID* APPROVED BY NAM PHONE M WITH AREA CODE h�TSP ZG PFA IT NUMBER PP(eE/IRMITAPP OVA DATE PERMIT EXPIRATION DATE /V� CHECK N PERMIT AMOUNT SURCHARGE A . FEE CODE RECEIPT% BY: FORM FORM B(6-29-66) THIS MUST BE ACCOMPANIED A FACILITY/SRE APPLICATION, FORM 'A',UNLESS A CNI NT FORMA' HAS BEEN FILED DATA PROCESSING COPY