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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ozFORM `B': UNDERGROUND STORAGE TANK PROGRAMTANK PERMIT APPLICATION INFORMATION TANKCOMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 10 MARK ONLY ❑ 1 PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED C ONE ITEM 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 1 FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES Ll NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY OD A. OWNERS TANK ID# D .G) B. MANUFACTURED BY: -- C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK C ENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS OT MARKED,COMPLETE ITEM D. A. 1 MOTOR 41CLE FUEL ❑ 2 PETROLEUMB. C. ❑ 1 UNLEADED ❑2 LEADED EL F-13 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.W III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEELARON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE7 L UM F-18 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER ❑ 1 RUBBERUNED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑4 LIC LINING C. INTERIOR ,�,9/5 LINING ❑5 GLASSUNING ❑6 UNLINED UN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3V WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION E]5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A 1 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 A UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAT SSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 RGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 95 UNKNOWN A U 99 OTHER ////// Vqqqqq///.. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. ZPI 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE J: I 1. ESTIMATED DATE LAST USED(NTC YR 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH P ,N/ SUBSTANCE REMAINING IN GALLONSINERT MATERIAL? [-]YES ❑ NO THIS FORM HAS BEEN bomPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PH E#WITH AREA CODE Q 3 Z PERMIT NUMBER PERMIT APPROVAL DATE PERM E IRATION DA CHECK# PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: V- FORMBI6-29-13B THIS FORM MUST BE ACCOMPANI BYAFACILITY/SITE APPLICATION, FORM 'A',UNLESSAYUHRENT FORMA' HASBEENFILED DATA PROCESSING COPY