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STATE OF CALIFORN* WATER RESOURCES CONTROARD FORM B': UNDERGROUND STORAGE TANK PR RAM MPLETE �` TANK TANK PERMIT APPLICATION INFORMATION COA SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. o MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO NK ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE V8 TANK REMOVED O 9 FACILITY/SITE NAME WHERE TANK ISINSTALLEM (,U Z FARM TANK-YES❑ NO N f� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY p r A. OWNERS TANK ID# S. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Sbo 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 ❑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 A HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: Y� III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D 1 D UBLE WALLED ❑3 SINGLEWALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN A.TYPE OF ❑ SYSTEM 2 SINGLE WALLED ❑4 SECONDARYOONTAINMENT ❑ 99 OTHER Eja<STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEELCIADW/RBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 6100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER TERIO ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. N LINING R ❑5 GLASS LINING EBfUNLINED ❑95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAO OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE E�J4 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMA ION 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 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 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 A U 6 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 V LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. ND P S 1VISUALCHECK P S 2 INVENTORY RECONCILIATION 3VADOSEWELLS P S 4 ELECTRONIC MONITOR P 5 SGROUND WATER MONITORING WELLS pN � P S 6 PRECISION TESTING P S ] PRESSURE TES TING P 1 NONE P S 95 UNKNOWN P S 99 OTHER h VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE ST USED(MO/YR) 2. ESTIMATED OUANTI OF 3.WA TANK FILLED WITH SUBSTANCE REM ING IN IN TAIATERIAL? ❑YES ❑ NO GALLONS IJ'� THIS FORM djS BEEN COMPLETED UNDER PENALTY OF PERJ RY,AND TO THE BEST OF MY KNOVVLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# t [=o CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY N E PHONE#WITH AREA CODE Le W30 PERMIT NUMBER PERMIT APPROVAL DATE PER EXPIRATION DATE CHECK# PEflMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: Ah FORMB(6-29-8e) THIS FORM MUST BE ACCOMPANIE YAFACILITY/SITE APPLICATION, FORM 'A',UNLESS ATURRENT FORM'A' HASBEENFILED DATA PROCESSING COPY