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STATE OF CALIFORN' 1 WATER RESOURCES CONTE BOARD FORM 'B': ( ' , UNVERGROUND STORAGE TANK PROGRAM A ' TANK TANK PERMIT APPLICATION INFORMATION � COMPLETE A SEPARATE FORM WITH THE FOLLOWING INF ATION FOR EACH TANK. o MARK ONLY ❑1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ED oma• 10 Z ONE ITEM ❑2 INTERIM PERMIT ❑7 PERMANENTLY CLOSED TANK ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED O FACILITY/SITE NAME WHERE TANK IS INSTALLED: nn W � . G FARM TANK-YE NO N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY C711 A. OWNERS TANK ID# B. MAN�CAPACITY BY: u 00 C. YEAR INSTALLED D. TANGALLONS: S4,' A ... IL 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 ❑ i 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.# C.A.S.W III. TANK CONSTRUCTIO - MARK ONE ITEM ONLY IN BOX A,B,C,S D A TYPE OF ❑ I D D ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 S E WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑2 STAINLESSSTEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 IW%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER UNEO ❑2 ALKY ❑3 EPDXY UNING ❑4 PHENOLIC UNING LINING ❑5 GLASS LINING LINED ❑95 UNKNOWN ❑ISLINING MATERIAL OOMPATIBLEWITH 100%METHANOL? - ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑1 TAR456SPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PIlSTIC PROTECTION ❑ 5 CATHODIC PROTECTION91 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A UI;KNONEI_> 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 UK 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 5ALUMINUM A U 6CONCRETE A U 7STEEL CLAD W/FAP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U UNKNO 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 I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 NIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING 91 NONE P 8' S U O P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? DYES [—] 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCA NCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE TON � PERMIT NUMBER PERMIT APPROVAL DATE PERMREKPIRATION DATE [CHECK# PERMIT AMOUNT SUP14ARGE AMT. PEECODE RECEPT# tY: "— FORMB(6-29-66) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM'A',UNLESSACURRENT FORMA' HASSEENFILED —J) DATA PROCESSING COPY