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STATE OF CALIFORNI WATER RESOURCES CONTRA 30ARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COM LETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY EkKi NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLO4TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: D FARM TANK-YES❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 A. OWNERS TANK ID If C B. MANUFACTURED BY: U/c C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: L) V A II. TANK CO TENTS IF(Al),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. F-► A. - 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C ❑ 1 UNLEADED ❑ 2 LEADED IESEL ❑3 CHEMICAL PRODUCT ❑4 OIL r p( 4 GASAHOL ❑ 5 JETFUEL6 AVIATION GAS 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN TE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CA.S.N C.A.S.N: XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,SO A.TYPE OF ❑ 1 DOUBLEWALLED E33 SINGLE WAILED WITH EXTBKOR LINER ❑ 95 UNKNOWN SYSTEM �N6IP WA?lED 4 SECONDARY CONTAINMENT l , ❑99 OTHER 1:9- /IRON 2 STAIN STEEL ❑3 FJBERGLA$$ ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK / SCON(AETE 6 INYLCHLORDE MATERIAL ❑ ❑7 ALUMINUM ❑8 1OTHER IANOL COMPATIBLE FRP ❑ 9 BRONZE 16 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑4 PHENOUC UNING LINING ❑5 GLASS LINING INED ❑%UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%MEMANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑1 PoLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑3 VWYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION �❑ 5 CATHODIC PROTECTION E3 1r<NE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMAON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A rMl 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A 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 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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 P 8 2 INVENTORY RECONCILIATION P 8 3 VAOOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P PRECISION TESTING P 8 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 DATE LAST USED(MO/YR) 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. APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N ® = = 16 01 Cao CURRENTpLO�C�AL AGENCY FACILITY ID M APP BY PHONE N WITH AREA CODE L(/r-L� PERMIT NUMBER PERMIT, PRO AL gDATEEXPIRATION DATE PERMIT 1 / CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: FORM B(34-88) THIS FORM MUST BE ACCOMPANIES- A FACILITY/SITE APPLICATION, FORM 'A',UNLESS FORM'A' HAS BEEN RLED DATA PROCESSING COPY