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STATE OF CALIFORNUL WATER RESOURCES CONTRO' 'AOARD FORM 'B': UNDERGROUND STORAGE TANK PROuRAM TANK TANK PERMIT APPLICATION INFORMATION m� COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: ,�T (rte FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS IF UNKNOWN—SO SPECIFY LQ A. OWNERS TANK IDa B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY MGALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. Q A- ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM H C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ffi ❑3 CHEMICAL PRODUCT �4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑8 AVIATION GAS W ❑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&CAS.N QS L 1! C.A.S.a: I XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.t D A. TYPE OF ❑ 1 DOUBLEWALIED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM [21 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ®'1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 RBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 180%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 18 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS UNING [N-6 UNLINED ❑95 UNKNOWN ❑IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ®2 TAR OR ASPHALT ❑3 VINYLWRAP ❑4 FIBERGLASS REINFORCED 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 U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE G MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 1D0%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A(5>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. P S 1 VISUAL CHECK (o S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YRI 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY a JURISDICTION a AGENCY p FACILITY ID M TANK ID N O 1 a 3 do / O CURRENT,LOCAL AGENCY FACILITY IDN APPROVED BY NAME ONE N WITH AREA CODE � l � PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIM TE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTN BY: FORMB(3-7-8&) TIRE FORM MUST BEACCOMPANI IIBY A FACILITY/SITE APPLICATION, FORM`A',UNLESS URRENT FORM'A' HASBEENFILED DATA PROCESSING COPY