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STATE OF CALIFORNWATER RESOURCES CONTR vBOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION `� m COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. -- - Z 3M 1 0 MARK ONLY F-1I NEW PERMIT F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PE ANENTLY CLOSE ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ,L-1r1,'a TTAANK REMOVED Q w FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES P<O ❑ F+ 00 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY W A. OWNERS TANK ID# B. MANUFACTURED BY: (�{ C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: DO II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED DIESEL ❑ 3 CHEMICAL PRODUCT ❑4 OIL 1�40DUCT ❑ 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.# CA.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,8 D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM ❑2 SINGLE WAILED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑1 SIEELYIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4STEELCLADW/FIBERGLSSREINFORCEDPLA"C B. TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 IW%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED 5TEEL Fij<UNKNOWN ❑M OTHER C. INTERIOR F-11 RUBBER LINED ❑2 ALM LINING F-13 EPDXY LINING F-14 PHENOLIC LINING LINING ❑5 GLASSUNING ❑6 UNLINED 1NKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 109%METHANOL? ❑YES ❑ NO VOTHER 0. CORROSION ❑ i POLYETHLENE WRAP ❑2 TARORASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE EL�WORKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 4095 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 U 95 UNKNOWN A U W OTHER A U I STEEL/IRON A U 2 STAINLESSBTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A05 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 P 8 2 INVENTORY RECONCILIATION P 3 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 3 6 PRECISION TESTING P S ] PRESSURE TESTING NE P B 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING INGALLONS INERT MATERIAL? ❑YES ❑ 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# CURRE7 UOC4L A E Y FACILITY IDN APPROVED 117E PHONE#WITH AREA CODE A/ Or` PERMIT NUMBER PERMIT APPROVAL DATE I I P MIT EXPIRATION DATE Y1, CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: F FORM B(6-29-881 THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA HAS BEEN FILED DATA PROCESSING COPY