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STATE OF CALIFORN16 WATER RESOURCES CONTR OARD FORM 'B': UNDE GROUND STORAGE TANK PRO AM n' TANK TANK PERMIT APPLICATION INFORMATION - �- COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. " Z 10 MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT D<CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM F] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANKREMOVED � W FACILITY/SITE NAME WHERE TANK IS INSTALLED: I m�> E, Uou I IA' FARM TANK-YES❑ I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY (� A. OWNERS TANK ID# I B. MANUFACTURED BY: u C. YEAR INSTALLED O D. TANK CAPACITY IN GALLONS: %'00c) II. TANK CQMTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,CO ETE ITEM D. A. [9-i'MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. UNLEADED E] 2 LEADED E:] 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL B 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.W III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,Et D A.TYPE OF ❑ I DOUB ALLED F-13 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM INGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER EL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 6100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LININGn 4 P ODIC LINING C. INTERIOR � LINING ❑5 GLASS UNING ❑ 6 UNLINED 95 U NOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100% HANDL? ❑YES [-] u NO OTHER D. CORROSION ❑ I POLYETHLENEWRAP TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION E�] 5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A Ml SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A V 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 5 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 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL Yt>5 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 SI VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS .� P S 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 PLACE 1. ESTIMATED D TE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH N SUBSTANCE REMAINING IN 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# ml I I I 1 I YEE I I I IZ CURRENT LO L AGENCY FACILITY IDX APPROVEDBYhhNA E rp PHONE X WITH AREA CODE O J 1 v / PERMIT NUMBER PERMIT APPROVAL DATE ERMIf EXPIRATNJA 6ATE vij CHECK X PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT X BY: FORM B(529-BB) THIS FORM MUST BE ACCOMPANI A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORMA' NAS BEEN FILED DATA PROCESSING COPY