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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 IN FOR EACH TANK. _ MARK ONLY ❑ I NEWPERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑7 PERMANENTLY CLO ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED ' !S FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY �Q A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED cn 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. ❑ i MOTOR VEHICLE FUEL ❑ 2 PETROLEUM E0. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL F-13 CHEMICAL PRODUCT ❑4 OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL E:]6 AVIATION GAS ❑5 HAZARDOUS E] 80 EMPTY ❑95 KNOWN ❑2 WASTE E]7 METHANOL ❑99 OTHER(DESCRIBE IN REM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.N CAS.N: III. TANK CONSTRUCTION MARK ONE ITEM ONL IN BOX A,B,C,8 D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED RH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED 4 SECONDARY INMENT ❑99 OTHER ❑ I STEEL/IRON ❑2 STAINLESS,STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 10096 METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZ®STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ C. INTERIOR 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNUNED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 1O METHANOL? YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TARORASPHALT ❑ WNYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑�5 CATHODIC PROTECTION [ 91 NONE E-]95 NKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UND GROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U i SUCTION A U 2 PRESSURE A u\3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U i SINGLE WALLED A U 2 DOUBLE WALLED A U LINEDTRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 LYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 SIXEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 O ER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDA ,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P 5 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P S UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH SUBSTA14CE 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. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY N FACILITY 10 N f TANK ID# ail GInI5 D CURRE OCAL AGENCY FACILITY ID# APPROV DpYN M PHONE N WITH AREA CODE PERMIT NUMBER Cn PERMIT APPROVAL DATE (/� PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(5-29-813) THIS FORM MUST BE ACCOMPANIED BY A FA6ILPTY/SRE APPLICATION, FORM 'A',UNUl!%WK CURREI,JDRM'A' NAS BEEN FILED DATA PROCESSING COPY