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STATE OF CALIFORN WATER RESOURCES CONTP IOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM ' Y TANK PERMIT APPLICATION INFORMATION TTANKWING INFORMATION FOR EACH TANK. COMPLETE A SEPARATE FORM WITH THE FOLLOWING MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM r?'�INTERIM PERMIT ❑ 4 AMEND""ED,�PERMIT [1]6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED yI/. FACILITY/SITE NAME WHERE TANK IS INSTALLED: /Sip FARM TANK-YES❑ NO Rr z 10 I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# tq If B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: O0� II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. C2 A. gl MOTOR VEHICLE FUEL ❑2 PETROLEUM 8. C. UNLEADED ❑ 2 LEADED E] 3 DIESEL W ❑3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑1 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS E]5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWNFF-1 2 WASTE ❑7 METHANOL ❑99 OTHER(DESC IBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF /I HAZARDOUS SUBSTANCE STORED 6 C.A.S.# C.A.S.#: J� All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF ❑ I IE WALLED F-] 3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM 2 SINGLEWALLB3 ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEELIIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 A MINUM ❑8100%METHANOLCOMPATI6LEFRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑ 2 WDLINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑5 GLASS UNING 6 UNLINED ❑95 UNKNOWN ❑ B LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TARORASPHALT ❑ 3 LWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 14DNE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION ll(_U�l SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 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 C. MATERIAL A U 5 ALUMINUMA U 6 CONCRETE A U 7 STEELCLADW/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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. Il�rjJJ7 P S 1 VISUAL CHECK &S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P(IsDa PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONEP S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE TUSED(MO/YR) 2.ESTIMATED QUA ITY OF 3. WAS TAKILLED WITH SUBSTANC A ING IN GALLONS INE A L? ❑YES ❑NO THIS FORM AS BEEN COMPLETED UNDER PENALTY OF PE JURY,AND TO THE BEST OF MY KNOWLED E,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# EPERPirTNUMBER LOCAL AGENCY FACILITY ID t APPR VE BY AM PHONE t WITH AREA CODE N PE IT PP OVAL DA PERMIT EXPIRATION DATE PERMIT AMOUNT SURCH O MT. FEE CODE R�CEIPTN BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM'A',UNLESS AteAVENT FORMA' HAS BEEN FILED DATA PROCESSING COPY