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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION ., COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1 NEW PERMIT F-]3 RENEWAL PERMIT -]5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED NK j ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED 0� FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPE IFY 1 A. OWNERS TANK ID# CU, B. MANUFACTURED BY: C. YEAR INSTALLED s D. TANK CAPACITY IN GALLONS: (� W i II. TANK 9ONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. F-L A_ VI MOTOR VEHICLE FUEL F-12 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL g2 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.#: .Ill. TANK CONSTRUCTION MARK ONE iTEM ONLY IN BOK A,B.C,&D A TYPE OF ❑ I BLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER I STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGUSS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOLCOMPATIBLEFRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER F-1I RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 C. INTERIOR ENOUCUNING LINING ❑ 5 GLASSUNING ❑6 UNUNED 95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 OR ASPHALT ❑3 WNYLWRAP ❑4 RBERGLASSREINFORCm PLASTIC PROTECTION ❑5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A 21 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A NI 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U MOTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A J"S UNKNOWN A U 99 OTHER 1V LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. f ` 1 P 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 1 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTINGFS 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED C TE LAST USED(MO/YR) 2. ESTIMAT D UANTITY OF 3.WAST N FILLED WITH SUBS C AWING IN IN T IAL? ❑YES ❑ NO GALLONS THIS FOR HAS BEEN COMPLETED UNDER PENALTY OF ERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# D h I I Iq N ILI IC� [� CURRENT LOCAL•6yl4CY FACILITY ID# VE BY RYAME PHONEp WITH AREA CODE PERMIT NU BEER 1` S PE MIT OV DDA PERMIT E]IWRATION DATE • 1 CHPERMIT AMOUNT SURCHA GE MT. ` ECK• FEE CODE RECEIPT# BY: FORMB(3-7-88) THIS FORM MUST BE ACCOMPANIEUVYA FACILITY/SITE APPLICATION, FORM'A',UNLESS6d RENT FORMA' HASBEENFILED