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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 ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT L�j5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED /45-' FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ .5a' ' I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I� A. OWNERS TANK IDN B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: CA) 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 ❑2 LEADED ❑ 3 DIES/NC ❑3 CHEMICAL PRODUCT OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATq�N!GAS E]5 HAZARDOUS ❑ SO EMPTY [:]95 UNKNOWN OR-2 WASTE ❑7 METHANOL ❑99 OTHER(ASCRIBE IN ITEM D',SEJGOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF 1� HAZARDOUS SUBSTANCE STORED 8 C.A.S.N i ) CAS.N: < 2 =III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN % SYSTEM SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER �STEEUIRGN ❑2 STAINLESSSTEEL ❑3 FIBERGLASS ❑4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLDRIDE ❑7 ALUMINUM F-18 IW%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER F-11 RUBSERUNED ❑2 ALKYD LINING ❑3 EPDXY UNING F-] 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑6 UNLINED �UNKNOWN I : ISUNING MATERIALCOMPATIBLE WITH 100%METHANOL? [-]YES [:]NO ❑99 OTHER 1:1 D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAAORASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED NU RC PROTECTION ❑ 5 CAT140DIC PROTECTION ❑91 NONE 5215 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 Aq A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A UNKNOWN AA4U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE IPVC) A U 4 FIBERGLASS PI E C.MATERIAL A U 5 ALUMINUM A �U6�CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANIJL COMPATIBLE FRP /�r a- A U 9 GALVANIZED STEEL A VUNKNOWN 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 o 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P t 5 GROUND TER MONITORING WELLS nS 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 9/ NONE P 8 95 UNKNOWN P S 99 OTHHI VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE T 1. ESTIMATED DATE LAST USED IMONR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? [:]YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY IDM TANK ID M dI Oa I o / CURRENT LOCAL AGENCY FACILITY IDV APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMITAPPROVALDATE PERMIT O DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE RECEIPT• BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMP01150 BY A FACILITY/SITE APPLICATION, FORM`A',UNLE NIT FORM'A' NAB BSN FllEB c,1 S I DATA PROCESSING COPY