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STATE OF CALIFORNI4 WATER RESOURCES CONT�P""')�BOARD FORM `B': UNDERGROUND STORAGE TANK Pik RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ ifERMANENTLY CLOSED TPN ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE WfTANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1 S%t A. AA Wil FARM TANK-YES❑ NO .7 I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 7 A. OWNERS TANK ID# / B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TAN CONTENTS IF A 1 ,IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. �I A. Vj 1 MOTOR VEHICLE FUEL PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL 00 ❑ 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 8 C.A.S.# Al IA C.AS.#: Lk All. TANK CONSTRUCTION MARK ONE IAM ONLY IN BOX A,B,C,A D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 212 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIRBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B IW%METHANOL MATERIAL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZEDSIEEL '°UNKNOWN ❑99 OTHER C.INTERIOR F-11 RIBBER UNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING E] 4 PHENOLIC UNI NG LINING ❑5 GLASS UNING ❑ 6 UNUNED 524 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHINOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2TAR OR ASPHALT INYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE 21 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A / SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A [U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH 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 5 ALUMINUM A8 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION3VADOSE WELLS P 8 4ELECTRONIC MONITOR P S SGROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 1 NONEP 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED DU NTITY OF 3, WAST FILLED WITH 411 1SUBSTA R LNG IN INET IAL? ❑YES ❑ NO GALLONS THIS FOWA4HAh BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO WLED E,IS TRUE AND CORRECT. ININ,II APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE I I� LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# DE = = 10oli 16, 11 1 160n CURRENT LOCAL AGENCY FACILITY ID# "PRO ED BY AM PHONE#WITH AREA CODE GZ L PERMIT NUMBER PERMIT APPROVAL DATIF PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIEE A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY u DATA PROCESSING COPY