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STATE OF CALIFORt WATER RESOURCES CONT, BOARD FORM 'B': UNftRGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NPiYfEERMIT ❑3 RENEWALPERMIT MqTHINGE OF INFORMATION ❑ 7 PERMANENTZ ED TANK ONE ITE INTERIM PERMIT AMENDED PERMIT 1:16 TEMPORARY TANK CLOSURE 0 TANK REMO b FACILITY/SITE NAME WHERE TANK IS INSTALL ©C f}CgC leIPoAj FARM TANK-YES❑ NO I. TANK DESCRIPTIPNCOMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID B. MANUFACTURED rt/ no C. YEAR INSTALLE n� D. TANK CAPACITY IN GALLON U' 11. TANK CONTENTS 21 IF(a1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. CJ �E O A_ MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑ 1 UNLEADED ❑2 LEADED Ee- IESEL ,u g 3 CHEMICAL PRODUCT ❑ 4 OIL DUCT LI ❑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.# ( PA-IC C.A.S.W MI. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF /////''�/1❑ 1 DOU LE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER NKNOWN SYSTEM �5(' IE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEBUIRON ❑2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK `� ❑5 CONCRETE ❑6 POLYVIWL CHLORIDE F-17 ALUMINUM ❑81009E METHANOL COMPATIBLE FRP MATER ❑9 BRONZE ❑ 10 GALVANIZED STEEL �INKNOWN ❑99 OTHER ❑ C. 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY UNING 4 PHENOLICUNING 'W " J/ LINING (� F-15 GLASS LINING ❑fi UNLINED UNKNOWN 141 S LINING MATERIAL COMPATIBLE NTH IDD%METHANOL. / YES Vr/NO ❑99 OTHER j D. CORROSI 1 POLYETI4LENEWMP ❑2 TM OR ASPHALT F-13 VINYL WRAP ❑4 F18EPGU55 REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑.9FDRI(NOWN ❑99 OTHER IV. PIPING INFOR MAP" CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE l A SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER r B.CONSTRUCTIO A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER r/ A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE I C.MATERIAL 3/ A U 5 ALUMINUM A ONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U 9 UNKNOWN A U 99 OTHER DETECTIONSYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. S 1 VISUAL CHECK 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS PfV6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE- P 8 95 UNKNOWN P S 99 OTHER i VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTI ATED DATE UST USED)rM /YP) 2. ESTIMATED QUANTITY OF 3, WAS TANK BILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES E] NO I THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. I APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# T NK ID# = o I C) Ii C� T 3CILIT(/JYT D# AP �0#0 BY NAME PHONE WITH AREA CODEO7 " / WD / PERMIT NUMBER P T APPROVAL DA MT EXPIRATION DATE i CHECK# PERMIT AMOUNT -4URCHARGE AMT. FEE CODE RECEI M BY: FORM B(3-7-BB) THIS FORM MUST BE ACCOMPANIEDWi A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A C ENT FORMA HAS BEEN FILED DATA PROCESSING COPY