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STATE OF CALIFORNI WATER RESOURCES CONTR*OARD FORM `B': UND GROUND 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 'C ONE ITEM � ❑ 7 PERMANENTLY CLOSED TANK ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE M8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 701 O �Ic/1li d'* ,A,FARM TANK-YESNO N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-�BMI.ANUFACTURED C7 A. OWNERS TANK ID q BY: NC. YEAR INSTALLED y6 TNK CAPACITY IN GALLONS: ,5 II. TANK NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,C MPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 8 C. 1 UNLEADED ❑ 2 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 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^IILE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SI WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑25TAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE MATERIAL ❑ ❑fi PoLriINYL CHLORIDE ❑ 7 gLUMINUM ❑81DD%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑10 GALVANIZFDSTEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER UNED ❑2ALKYO LINING ❑3 EPDXY LINING 4 NOCK LINING LINING ❑5 GLASS LINING ❑6 UNUNED b�r95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? DYES NO ❑99 OTHER D.CORROSION ❑ 1 PoLYETHLENEWPAP ❑2 TAR OR ASPHALT LWPAP 3 ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE LP195 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 5 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 S ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER A U B 100%METHANOL COMPATIBLE FRP V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. D// P S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 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 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/VR) 2. ESTIMATEDOUANTITY OF SUBSTANCE REMAINING IN 3 WAS TANK FILLED WITH GALLONS INERT MATERIAL? ❑YES ❑ 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# JURISDICTION q AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY ID# 0 F APPROVED BY NAME PHONE#WITH AREA CODE / 6 IL PER NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CNECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT FORM B(6-29-68) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED J DATA PROCESSING COPY