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STATE OF CALIFORN& WATER RESOURCES CONTROARD FORM 'B': UNDERGROUND STORAGE TANK PR RAM ' - LL TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION [:] 7 PERMANENTLY CLOSED TANK 10 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANKREMOVED O/ /'' W FACILITY/SITE NAME WHERE TANK IS INSTALLED: 6 ` � WZ FARM TANK-YES❑ NOff (� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY N /; CJ'i A. OWNERS TANK ID#V B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: OD 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 PETROLEUM B. C. ❑ 1 UNLEADED LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL ErPRODUCT 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 OTOR VEHICLE FUEL,ENTER C.A.S.NAME OF HAZAR OUS SUBSTANCE STORED& # A� C.A.S.#: N III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D I OUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN A.TYPE OF ❑ SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYL,CHHWRIDEE, F-17 ALUMINUM E]8100%METHANOL COMPATIBLE FRP MA`TER'I4L ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING C. LIN NRIOR ❑5 GLASS LINING �6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 1SUNKNOWN ❑99 OTHER IV. PIPING INFORM ON 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 91 NONE A U 95 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 A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6CONCRETE A U '7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A el 5 UNKNOWN A U 99 OTHER V. LEAK DETECTION YSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. S P 5 1 VISUAL CHECK 5 2 INVENTORY RECONCILIATION 8 3 VADOSE WELLS P 3 4 ELECTRONIC MONITOR P 3 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATELA T SED(MO/YR) 2. ESTIMATED UANTITY OF 3,WAS TAN ILLED WITH �� SUB A fJAINING IN IN RT IAL? ❑YES [:] NO ,V GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY Of PERJURY,AND TO THE BEST OF MY KNOwLE6GE IS TRUE AND CORRECT, APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# olo1 6 I 3 I � I DD I D / CURE TTLLOCCAALL AAGEENNCY FA LITY ID# APPROV SY PHONE#WITH AREA CODE 77 . PERMIT NUMBER PEgM1�PP�VAL DAT PERMIT EXPIRATION DATE ICHECK# PERMITAMOUNT SURCHARRGEA T. FEE CODE RECEIPT# BY: \VII FORM B(6-29-fie) THIS FORM MUST BE ACCOMPANIE r A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A MAENT FORM'A' HAS BEEN FILED S DATA PROCESSING COPY