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STATE OF CALIFORNIS WATER RESOURCES CONTR OARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C o K ONE ITEM ❑2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED Lyi FACILITY/SITE NAME WHERE TANK IS INSTALLED: s FARM TANK-YES❑ NO z I I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY t A. OWNERSTANKID# O "Z/ S. MANUFACTURED BY C. YEAR INSTALLED4!2 D. TANK CAPACITY IN GALLONS: vQ iE II. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. kl'l MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. EV UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑ 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 VEHICLEfUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF 1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEBUIRON ❑2 STAINLESSSTEEL ❑3 FIBERGLASS [V:] 4 EL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM %METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER LINED ❑2 DLINING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING F-15 GLASS UNING 6 UNLINED ❑95 UNKNOWN ❑ ISUNING MATERIALCOMPATIBLE WITH 1M%METRANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHUENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFAS VE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A LV 2PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH 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 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A®6 100%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. TN_) P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P VADOSE WELLSUP S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P ] PRESSURE TE STING P 1 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DAT LAST USED(MO/YR) 2. ESTIMATEDO ANTITY OF 3.WAS TA FILLED WITH SUBST CGALLONS 3% WING IN ART AT IAL? ❑YES ❑ NO THIS FOR HAS BEEN COMPLETED UNDER PENALTY OF ERJURY,AND TO THE BEST OF MY KNOWLE GE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 0U 1 l wv 3 40 D CURRENTLOCALAGENCY FACILITY 10 pPP E E PHONE#WITH AREA CODE c �� PERMIT NU BER PERMIT APPROVAL DATE f PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT URCHARGE AMT. FEE CODE ECEIPT# BY: FORMB(3-7-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A,UNLESS A CURRENT FORMA' HASBEENFILED DATA PROCESSING COPY