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STATE OF CALIFORNI% WATER RESOURCES CONTRO ARD FORM `B': UNDERGROUND STORAGE TANK PROGAM =� �� TANK /�� TANK PERMIT APPLICATION INFORMATION �/ COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK.1 NEW PERMIT —, z MARK ONLY 3 RENEWAL CHANGE OF INFORMATION Ll 7 PERMANENTLYC Y'oP0 '- ❑ ❑ NK 1 ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED / FACILITY/SITE NAME WHERE TANK IS INSTALLED: �a &V FARM TANK-YES❑ NO # I. TANK DESCRIPTION COMPLETE ALL ITEMS-IFUNKNOWN-SO SPECIFY y7� A. OWNERS TANK ID# B. MANUFACTURED BY: 0 C. YEAR INSTALLEDLl D. TANK CAPACITY IN GALLONS: lajz9oo IL TANK 96NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. LEA A. 1 MOTOR VEHICLE FUEL F-12 PETROLEUM C. ❑ 1 UNLEADED 2 DED 3 DIESEL B. ❑3 CHEMICAL PRODUCT ❑ 4 OIL 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.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D Ea �� A. TYPE OF UBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM IE9 2 INGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER B. TANK1 STEBUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCEDPLASTIC MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING n 4AHENOUC LINING LINING ❑5 GLASS LINING ❑6 UNLINED LLJ?/9 NKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 99 OTHER 1). CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TARORASPHALT ❑ NYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF E GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A ?Z2 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 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 A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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. D(✓^/ P 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS S 8 PRECISION TESTING P 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 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 IN GALLONS INERT MATERIAL? EDYES ❑ 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# LoJ o I / o !F- ez CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE V,p PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# - BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED