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STATE OF CALIFORN9 WATER RESOURCES CONT BOARD FORM B': UNDERGROUND STORAGE TANK PRI RAM TANK TANK PERMIT APPLICATION INFORMATION co,� COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ z MARK ONLY ❑ I NEWPERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLiN ANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED N FACILITY/SITE NAME WHERE TANK IS INSTALLED: 13 2 O by , FARM TANK-YES❑ O 41k I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Q GT1 A. OWNERS TANK ID q 13 R. MANUFACTURED BY: co C. YEAR INSTALLED (J D. TANK CAPACITY IN GALLONS:10 0 Il. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,C91116LETE ITEM D. A. FV1 MOTOR VEHICLE FUEL ❑2 PETROLEUMB. C. [2'1'UNLEADED ❑ 2 LEADED ❑3 DIESEL F ]3 CHEMICAL PRODUCT ❑ 4 OIL VRODUCT ❑ 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 CONSIT—I/RUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D 1_ A. TYPE OF DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 GIE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIggg"GLASS ❑48'TEELCLAD W/FIBERGLASS REINFORCED PLASTICB.TANK ❑ MATERIAL 5 CONCRETE ❑6 POLYVINYLCHLORIDE n yALUWUM ❑8100%METHANOL COMPATIBLE FAP L}�� ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 5 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RUBBERUNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 ENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED 95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP ❑ 2 TAO OR ASPHALTINYL WRAP ❑4 RBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION E] 91 NONE M UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U / SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A95 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 6 95 UNKNOWN A U 99 OTHER A 6 1 STEEL/IRON A U 2 STAINLESS STEEL 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 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. r-� P S 1VISUALCHECK S 2 INVENTORY RECONCILIATION P 8 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS VV P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITYID# APPROVED BY NAME PHONE#WITH AREA CODE UN1oN l3 W PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED ,. DATA PROCESSING COPY ,