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STATE OF CALIFORNI WATER RESOURCES CONTRC IOARD FORM 'B': UNDERGROUND STORAGE TANK PR66RAM TANK TANK PERMIT APPLICATION INFORMATION (az COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 10 MARK ONLY ErllNEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMI ^g' FACILITY/SITE NAME WHERE TANK IS INSTALLED: L/V. FARM TANK-YES❑ NO C,JT I.s I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY N A. OWNERSTANKID# B. MANUFACTURED BY: A C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS' Q 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 [D 2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL F 1 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 A C.A.S.# C.A.S.M P III. TANK CONSTRUCTION MARK ONE ITEMONLYIN BOXA,B,C,A0 A. TYPE OF ❑ DOUBLEWALLED F-] 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM g SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER f STEEUIRDN ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑6100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYO LINING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING UNLINED ❑ 95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? [:]YES ❑ NO OTHER ✓ D. CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TARORASPHALT ❑3 LWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMAT ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE USUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION U SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE 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 A U 91 NONE C. MATERIAL A U 5 ALUMINUM ACONCRETE A U 7 STEEL CLAD W/FRP A U 8100%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. /T P S 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P B 3 VADOSE WELLS P B 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 6 PRECISION TESTING S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S W OTHER I. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIM TED DATE LAST USED(MO/YR) 2, ESI TEDOU INE OF 3.W NKFILLED WITH - I I �L S REMAINING IN ATERIAL? ❑YES ❑NO /V r GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOVIlLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# lob lo I CURRENT LOCAI.AGENCY FACILITY D# APPROBY NAME w PHONE#WITH AREA CODE PERMIT NUMBER PERMITAPPRO A AT L/PERMIT EX IRATION DATE f/pf�/"� (J¢ i ^ / CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: U FORV 13(6-29-56) THIS FORM MUST BE ACCOMPAN16 Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS AGENT FORMA' HAS BEEN FILED DATA PROCESSING COPY _ _