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STATE OF CALIFORN WATER RESOURCES CONTF& BOARD "•• •. FORM 'B'- UND RGROUND STORAGE TANK PR GRAM y�`" P TANK 0� TANK PERMIT APPLICATION INFORMATION ` ;;im. COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. IC MARK ONLY ❑ I NEW PERMIT ❑3 RENEWALPERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED i'TQ FACILITY/SITE NAME WHERE TANK IS INSTALLED: V FARM TANK-YES NO a WW Cr I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY �+ E OWNERS TANK IDB B. MANUFACTURED BY: N YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,CO ETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. - C. 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ SO 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.M C.A.S.B: III. TANK CONSTRUCTIO,N MARK ONE ITEM ONLY IN BOX A,B,C,8 D A TYPE OF ❑ I LE WALLED E]3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM SING ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEUIRON ❑ 2 STAINLESSSTEEL ❑3FIBERGLASS ❑ 4STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC S.TANK F7 CONGREfE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ I RUBBER LINED ❑2 LINING E]3 EPDXY LINING ❑4 PHENOLIC LINING C.INTERIOR LINING F-15 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 1 OD%ME'TW400 ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLFNEWRAP ❑2 T RASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION 1 NONE ❑95 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 A U 91 NONE 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 k U 95 UNKNOW A U 99 OTHER Q 1 STEEL/IRO 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 S CONCRETE A U 7 STEELCLAD W/FRP A U B 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 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VAOOSE WELLS P 8 4 ELEC NIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S S PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 95 UNKNOWN P B 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 ❑ 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 Y JURISDICTION B AGENCY B FACILITY ID B TANK ID Y % = = I © I C) a o 1 v CURRENT LOCAL AGENCY FACILITY ID F APPROVED BY NAME PHONE B WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CNECK• PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT 4 BY: FORM B(5-29.93) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY