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STATE OF CALIFORN; WATER RESOURCES CONTRI„r BOARD - o. FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT gTANK ONEITEM ❑5 CHANGE OF INFORMATION 7 ERMANENTLY CLOSED1O ❑2 INTERIM PERMIT ❑4 AMENDED PEflMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED 623 FACILITY/SITE NAME WHERE TANK IS INSTALLED: S"CFARM TANK-YES NO 1. TANK DESCRIPTIONCOMPLETE ALL ITEMS-IF UNKNOWN- N SO SPECIFY W A. OWNERS TANK IDNaz B. MANUFACTURED BY: ~ C. YEAR INSTALLED q Ln D. TANK CAPACITY IN GALLONS: V�0 11. 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 PETgOLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑q OIL 21-Fl ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM O,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.ICDA/A 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D I WE WALLED L] 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN A TYPE OF ❑ SYSTEM LLJ 2 SlNGV WALLED ❑4 SECONDARYCONTAINMENT 99 OTHER 1 STEEUIRON 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CUD WIRBERGLASS REINFORCED PLASTIC S.TANK MATERIAL 5 CONCRETE ❑6 POLYVINYLCHLORIDE 7 ALUMINUM E]8100%MEfHANOLCOMPATIBLEFRP ❑9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER C. INTERIOR ❑ I RUBBERUNED ❑PA"LINING 3 EPDXY LINING 4 PHENDUC UNING LINING ❑ 5 GLASS UNING 6 UNLINED ❑95 UNKNOWN ( � ❑ IS UNING MATERIAL COMPATIBLE WITH IOD%METHANOL? ❑YES ❑ NO OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT 3 VI LWRAP 4 FIBERGLASS REINFORCED PLASTICPROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE U A UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 F ERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U�CONCRETE A U 7 STEELCLAI)W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A 5 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. N P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING pass S 1 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTI ATED DATE LAST USED(MO/YR) 2 ESTIM ED QUANTITY OF 3. AS TANK FILLED WITH B CE REMAINING IN GALLONS RT MATERIAL? ❑YES NO THIS FORM HAS BEEN COMPLETED UNDER PENAL OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION# AGENCY# FACILITY ID# TANK ID# m = = 1616g [600 , CURR NT OCAL A lEFFA I # APPROVED BY NAME PHONE N WITH AREA CODE (� 4 l� 2 PERMIT NUMBER PERMIT APPROVAL DATE PERATWEXPOUtTiblif DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: I FORM B(6-29-w) THIS FORM MUST BE ACCOMPANIES A FACILITY/SITE APPLICATION, FORM `A',UNLESS A ZuRRENT FORMA' HAS BEEN FILED