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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. _— Z `f•o 10 MARK ONLY F-11 NEW PERMIT F]3 RENEWALPERMIT V 5 CHANGE OF INFORMATION [:] 7 PERMANENTLYC K ONE ITEM F-12INTERIM PERMIT F-] 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED /� FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO A I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY (D A. OWNERS TANK ID# MANUFACTURED BY: 14*-#z-J C. YEAR INSTALLED ` D. TANK CAPACITY IN GALLONS II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED C] 2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT P'4 OIL er1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL � OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF �]�L� Tq HAZARDOUS SUBSTANCE STORED&CA.S.# [ C.A.S.#'. J v III. TANK CONSTRUCTION MARKONE ITEM ONLYIN BOXAB,C,BD A. TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EOTRIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STRARON ❑2 STAINLESS STEEL ❑3FIBERGtASS ❑4MEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑6100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYDUNING ❑3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING ❑5 GLASS LINING Q'6 UNLINED ❑ 95 UNKNOW? ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NOOTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TARORASPHALT ❑3 VINYLWRAP ❑ 4 RBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ff95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A 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 POLWINYLCHLOBIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 6 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 1 VISUAL CHECK 2 INVENTORY RECONCILIATION P 8 3 VAOOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS 6 PRECISION TESTING B 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATE1 DATE LAST USED MO/YR) 2. ESTIMATE UANTITY OF 3.WASTAN FILLEDWITH SUBS EMAINING IN GALLONS IN RT TRIAL? ❑YES ❑ NO THIS ORM HAS BEEN COMPLETED UNDER PENALTY OfF 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# ' � 6 0 CURRENT LOCAL A`G�EHGY FACILITY IDN pPP BV NAME j PHONE#WITH AREA CODE PERMIT NUMBER G PERMIT APPROVAL DATE J PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: S FOHM B(6-29-66) THIS FORM MUST BE ACCOMPANIENY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A'TORRENT FORMA' HAS BEEN FILED J