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WATER RESOURCES CONTR OARD ''r STATE OF CALIF�DRNI s FORM `B': UND ROUND STORAGE TANK PRO RAM � o TANK PERMIT APPLICATION INFORMATION TANK u COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. O MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT D>eHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED �3 FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO 4b.to TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN SPECIFY CA co A. OWNERS TANK M# B, MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: ©057 II. TANK C ENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,CO TE ITEM D. A. 7 MOTOR VEHICLE FUEL 2 PETROLEUM B. G. UNLEADED ❑ 2 LEADED ❑ 3 DIESEL F-] 3 MOTOR VE PRODUCT F-1 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL E] 6 AVIATION GAS F-1 5 HAZARDOUS F-160 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF CAS N. HLA'ARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I D WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT a 99 OTHER ❑ 1 STEELIIRON ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGLASSREINFORCED PLASTIC B.TANK ❑ 5 OONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ I RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPCXY LINING ❑4 PHENO LINING C. INTERIOR I—I 5 GLASS LINING F-] 6 UNLINED UNKNOWN LINING I� �E:] ❑ [:] O � �� ISLININGMATERIAL COMPATIBLE WITH 100%METHANOL? YES No D. CORROSION ❑ I P HLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A SYSTEM TYPE A U 1 SUCTION A U 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 U UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U-4 CONCRETE A U 7 STEEL CLADWfFRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 5 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S VISUALOHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S PRECISION TESTING S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PE MANENTLY CLOSED IN PLACE 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH 1. ESTIMATED DATE LAST USEp{M01 R) SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO ��IL/f/ GALLONS THIS FORM HAS BEEN COMPLETED LENDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, fS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK IDS# T APPROVED BY NAME NE 4 WITH AREA CODE CURRENT LOCAL AGIMY FACILITY Ip# , 0 PERMIT NUMBER PERMIT APPROVAL DATE P RMIT E IRATION PAT CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY. FORM B(6-29-sB) THIS FORM MUST BE ACCOMPANI - A FACILITY/SITE APPLICATION, FORM `A',UNLESS A RENT FORM W HAS BEEN FILED DATA PROCESSING COPY