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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM ` TANK TANK PERMIT APPLICATION INFORMATIONo COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. :a MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT lug CHANGE OF INFORMATION 7 PERMANENTLYK ONE ITEM F—] 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED:i zJ lv FARMTANK-YES❑ NO L Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 10 A. OWNERS TANK ID B. MANUFACTURED BY. C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A rl MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL N 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CAS.# A C.A.S.#' A All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOIL A.B,C,A 0 A.TYPE OF ❑ DDISLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN BYBTEY vSINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER El�l STEBUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CIA[)W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8180%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑5 GUSSUNING W 6 UNLINED ❑95 UNKNOWN ❑ IS UNING MATERIAL CDMPATIBLEWTTH 10091 METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑2�,TP OR ASPHALT ❑3 VINYL WRAP ❑1 FlBERGLASSREINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION J2191 NONE ❑ 95 UNKNOWN 99 OTHER IV. PIPING INFORMA ON CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A (U41 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C.MATERIAL A U S ALUMINUM A e CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U 95 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S S GROUNDWATER MONITORING WELLSi P 6 PRECISION TESTIN 8 7 PRESSURETESTING P 8 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED D TE LAST USED(MOLAR) 2. ESTIM ED QUANTITY OF 3. WAS T K,PILLED WITH , SUB gl♦rE REMAINING IN GALLONS T ERIAL? '❑YES ❑ NO THIS FOFIM HAS BEEN COMPLETED UNDER PENAL OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# ® 6o f Is 3 a ;PERMIT RENT LOCAL ADENCY FACILITY ID# APP ED BY ME%ti� PHONE#WITH AREA CODE L,oD l )1 NUMBER PERMIT APPROVAL DAT PERMIT EXPIRATION DATE I`�' CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT M BY: `FORM e(3-7-ee) THIS FORM MUST BE ACCOMPA Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS'A'MRENT FORMA' HAS BEEN FILED (� DATA PROCESSING COPY \�