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STATE OF CALIFORNIt WATER RESOURCES CONTROI -OARD FORM 'B': UNDEMROUND STORAGE TANK PRO MAM TANK TANK PERMIT APPLICATION INFORMATION COMP ETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY1 NEW PERMIT ❑ 3 RENEWALPERMI7 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED t7 FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I� A. OWNERS TANK IDN -'r- B. MANUFACTURED BY: C. YEAR INSTALLED .Y D. TANK CAPACITY IN GALLONS: az 000 IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. 1 a A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETRO M B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT IL ❑ 1 PROD T ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS 1:1 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ASTE ❑7 METHANOL THER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF ✓ HAZARDOUS SUBSTANCE STORED&C.A.S.N CALS.M S x1f 1. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN �U SYSTEM ❑2 SINOLEWALLED ❑4 SECONDARY CONTAINMENT �99 GTHER L I nad, E.1 3TEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS43EINFORCED B. TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8180%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑%OTHER C. INTERIORF-11 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOUCUNING LINING ❑5 CUSS LINING ❑6 UNLINED #KNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2TAR OR ASPHALT L-1+1'O"""WRAP ❑ 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 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(U'>5 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 RBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U %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 8 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S S GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER Li VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LASTAISED(MO/YR) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH 'N/ SUBSTANCE REMAINING IN GALLONSINERT 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 N JURISDICTION# AGENCY N FACILITY ID R TANK ID# = = = l0l (Ql / l(Fk7 [3j0 CURRENT L CAL AGENCY FACILITY 10 N APPROVED BY M� �� PHONE Y WITH AREA CODE PERMIT NUMBER U PERMIT APPROVAL DA PER TEXPIRATIO ATE \\ [CWCK�ITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: vORM B =..7.881 THIS FORM MUST BE ACCOMPAN ., FACILITY/SITE APPLICATION, FORM 'A',UNL NT FORMA' IAS BEEN FILED DATA PROCESSING COPY