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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD "• FORM 'B': UNDERGROUND STORAGE TANK PROGRAM ® TANK PERMIT APPLICATION INFORMATION ' TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. i0 MARK ONLY ❑ 1 NEW PERMIT Q 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION [--] 7 PERMANENTLY CLOSED TA ONE ITEM 2 INTERIM PERMIT M 4 AMENDED PERMIT .y�� 6 TEMPORARY TANK CLOSURE [v 8/TANK REMOVED O FACILITY/SITE NAME WHERE TANK IS INSTALLED: Z Y c,tGl., FARM TANK-YES❑ NO C.J I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY O A. OWNERS TANK ID# B. MANUFACTURED BY'. C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 400 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. &fl MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED 2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT F-1 4 OIL PRODUCT ❑ 4 GASAHOL 5 JET FUEL 6 AVIATION GAS E15 HAZARDOUS ❑ 80 EMPTY 0 95 UNKNOWN 2 WASTE El 7 METHANOL 99 OTHER (DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF A C.A.S.#'. HAZARDOUS SUBSTANCE STORED 8 C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF F--�yI ,'TOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM LJ `SINGLE WALLED F� 4 SECONDARY CONTAINMENT E] 99 OTHER 1 STEEL/IRON ❑ 2 STAINLESS STEEL [:] 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK F-] 5 CONCRETE F-1 6 POLYVINYL CHLORIDE F-� 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE F-] 10 GALVANIZED STEEL [:] 95 UNKNOWN 99 OTHER I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING C. INTERIOR Ej 5 GLASS LINING UNLINED ❑ 95 UNKNOWN LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? E]YES E] NO OTHER rD. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC ECTION 5 CATHODIC PROTECTION � 91 NONE %UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFA EGROUND, 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 95 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 U 95 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 A6 CONCRETE A U 7 STEEL CLAD WERE A U 8 100%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 S I VISUALCHECK P S 2 INVENTORY RECONCILIATION 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P"a P S 6 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 ATE LAST USED(MO/YR) 2. ESTIMAT D OUANTITY OF 3. WAST.NK FILLED WITH A SUB TQ REMAINING IN N GALLONS TERIAL? YES D NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY dF 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# CURRENT, LCCALLA AGENCY IO# APPROVED BY NAM PHONE#WITH AREA CODE PERM IT ITT_N(UMBBERR PERMIT APPROVAL DATE PERMIT EXPIRATION DATE / CHECK# PERMIT AMOUNT URCHARGE AMT. FEE CODE RECEIPT# BY: \V11`�/ FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIED FACILITY/SITE APPLICATION, FORM'A',UNLESS 01411111WElff FORMA' HAS BEEN FILED DATA PROCESSING COPY