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STATE OF CALIFORNIA WATER RESOURCES CONTROL *)ARD FORM B': UNDEO"GROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. (az MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT ISCHANGE 10HANGE OF INFORMATION ❑7 PERMANENTLY CLOS TANK ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# :f74 3 1 B. MANUFACTURED BY: C. YEAR INSTALLED �j� I D. TANK CAPACITY IN GALLONS: IL TANK C ENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF IRA),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ESEL 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.M - III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUG WALLID ❑3 SINGLE WALLED WTTH EXTERIOR LINER 95 UNKNOWN SYSTEM NGLE ED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEL/IRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED 5fEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBERLINED ❑2 DUNING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING UNLINED ❑95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL' ❑YES ❑ NO OTHERUA D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 T ASPHALT ❑3 VINYL WRAP ❑/FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION 1 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A 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 An 95 UNKNOWN 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 5 ALUMINUM A U S CONCRETE A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STE3 AO 95 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. S VISUAL CHECK 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P t 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS PRECISION TESTING P t ] PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P 8 99 OTHER o[l . INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE UST USEQ( O/YR) 2. ESTIMATED QUANTITY OF GALLONS 3. WAS TANK FILLED WITH �`l// SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BE N COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# / = 101010 3 1j CURRENT LOCAL AGENCY fACILITY IDN APPROVED BY IIA EPHONE N WITH AREA CODE S // 3 8� IERMIT NUMBER PERMIT APPROVAL DATE pEpMrr EXPIRATI N DATE I \WL II CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: I FOPV e(es9-ee) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/STTE APPLICATION, FORM 'A',UNLESS AftRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY