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STATE OF CALIFOR WATER RESOURCES CONT BOARD FORM `B': UND GROUND STORAGE TANK PRRAM TANK TANK PERMIT APPLICATION INFORMATION o �° COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. `,•.o:�'' MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM HERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED , FACILITY/SITE NAME WHERE TANK IS INSTALLED: O a 5 cS-f' FARM TANK-YES 0 NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—$O SPECI e A. OWNERS TANK!D 0 B. MANUFACTURED BY: 4f C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK C TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.I(&I),IS NOT MARKED.C LETE ITEM D. A• 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C.� 1 UNLEADED ❑2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 01L I PRODUCT 4 GASAHOL ❑ 5 JET FUEL 6 AVIATION GAS ❑ 5 HAZARDOUS 80 EMPTY 95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL 99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.A C.A.S.0: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,&D A.TYPE OF ❑ 1 DOUBLE WALLED 3 SINGLE WALLEOWRH R ERIOR LINER %UNKNOWN '•• SYSTEM II0 11 2 SINGLE WALLED �4 SECONDARY COVTAINMFNT D99 OTHER S.TANK u I STEEUIRON 2 STAINLESS STEEL 3 FIBERGLASS ❑4 STEEL CLAD WIRBERGLASS REINFORCED PLASnc MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE 7 ALUMINUM 6 100%METHANOLCOMPATIBLE FRP ❑9 BRONZE ❑ 18 GALVANIZED STEELyr55 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYDLINING ❑3 EPDXY LINING 4 PHENOUC UNING LINING ❑5 GLASS LINING 6 UNUNFD UNiQm 15 UNTNG MATERIAL COMPATIBLE WITH 100%MMfWL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYETRENE WRAP 2 TAR OR ASPHALT ❑3 VI WRAP 4 FlBEAGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION 91 NONE 7000 ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE T A O 5 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 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FAP A U 9 GALVANIZED STEEL AU&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. j � P 6 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS �►T P& PRECISION TESTING P S 7 PRESSURE TESTING P 6 91 NONE P 6 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING INGALLONS INERT MATERIAL? ❑YES D NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION M AGENCY N FACILITY ID 4 TANK ID# lim I I �IV 3 1010101 CURRENT LOCAL AG4cNCY FACILITY ID#F APPROVED Y NAME^ PHONE A WITH AREA CODE PEAMINUMBER PERMIT APPROVAL DATE MIT EXPIRATION DATE CHECK R PERMIT AMOUNT SURCHARGE AMT. FEE CODE .RECEIPT R =e BY: .I RM B(6-29-w) THIS FORM MUST BEACCOMPANIEUWA FACILITYISITE APPLICATION, FORM `A',UNLESS A CURRENT FORMA' HAS BEEN FILED V DATA PROCESSING cnov