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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION quo COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ _ - Z i 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: N FARM TANK-VES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 00 A. OWNERS TANK IDN 0 ' B. MANUFACTURED BY: 'J C. YEARINSTALLED IC� 0 D. TANK CAPACITY IN GALLONS: '300 II. 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 Fe�2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL AR] 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 8 C.A.S.N C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A. TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM aY2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER B. TANK Eq! 1 STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CUD WYRBERGLASS REINFORCED PLASTIC MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER UNED ❑2 ALKYD UNING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING 06 UNLINED ❑95 UNKNOWN Z� / ❑ ISUNING MATERIAL COMPATIBLE WITH IDO%METHANGL? ❑YES [-] NO EA9OTHER 1"',,�•^"_ D. CORROSION ❑ 1 POLYETHLENE WRAP Eg2 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 01 SUCTION A U 2 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 U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE %UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(WC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U S ALUMINUM ACONCRETE A U 7 STEEL CLAD W/FOP A U 8100%METHANOL COMPATIBLE P A U 9 GALVANIZED STEEL A 1U96 FRUNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 8 1 VISUAL CHECK P 8 2 INVENTORY R%NCIUATION 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS 6 PRECISION TESTING P S 7 PRESSURE TESTING 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE ST USED(MO/YR) 2. STIMATEDOUANTITYOF WAS TANK FILLED WITH UBSTANCE REMAINING IN /I #ERT MATERIAL? ❑YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PEN LTY OF PERJURY,AND TO THE BEST OF MY K 0WLEDGE IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID R TANK ID A CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE C � PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATI011 DATE I CHECK# PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: L.�l FORM B(6-29-m) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A C RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY