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STATE OF CALIFORNIJ& WATER RESOURCES CONTROIrARD FORM 'B': UNDERGROUND STORAGE TANK PRO AM TANKTANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 'SCHANGE OF INFORMATION ❑7 PERMANENTLY CLOS*TAKONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED C FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANKNW I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY (� A. OWNERS TANK 0# B. MANUFACTURED BY: N C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: _ II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ,, 1 MOTOR VEHICLE FUEL F-12 PETROLEUM C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT ❑ B.4 OIL x1PRODUCT ❑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&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLEWALLED 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑2 SINGLEWALLED 4 BE CONDARYCONTAINMENT ❑ 99 OTHER ❑ 1 STEEL/IRON ❑ STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CIAO WFIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE ❑6X0LYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 LVANIZEO STEEL ❑95 UNKNOWN ❑99 OTHER 1 RUBBER LINED ❑ 2 AL LINING ❑ 3 EPDXY LINING ❑ 4 PHENOUC LINING LINING ❑ C. INTERIOR 5 GLASS LINING FJ 6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%M HANDL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR AS ALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROU D, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSU 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 POLYVINYLCHLORIDE(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 8 100%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. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 3 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 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 PL CE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES E] 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# - 33 16ao 171 CURRENTLOCAL AGEN 'FACILITY ID N_ APPROVED,By NAIPE PHONE#WITH AREA CODE PERMIT NUMMBBER 3 a(�' PERMIT APPROVAL DATE RMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: �1 ' FORM D(6-29-BB) THIS FORM MUST BE ACCOMPANIECWA FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY