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> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM B': UNDERGROUND STORAGE TANK PROGRAM TANKTANK PERMIT APPLICATION INFORMATION TANK. COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH 10 MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 P RMANENTLY CLOS NK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT �I❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY � A. OWNERS TANK ID N B. MANUFACTURED BY: C. YEAR INSTALLED 63 D. TANK CAPACITY IN GALLONS: Zs V II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ I UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ;�4 OIL ❑ 1PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY E]95 UNKNOWN ©2 WASTE ❑7 METHANOL rjE 9 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.N C.A.S.N. O III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 OUBLE WALLED ❑ 3 SINGLE WALIEDWITH EXTERIOR LINER ❑S5 UNKNOWN SYSTEMSINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRDN ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC UNING C.INTERIOR ❑ 5 GLASS LINING ❑UNLINED ❑9 UNKNOWN T '— LINING F-1ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 990THEP D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 INYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE WuNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDER ROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION 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 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A AS CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A LV 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. I P S 1 VISUALCHECK P S 2 INVENTORY RECONCILIATION P S VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S i NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. E TIMATED DATE LAST USED(MO/YR) 2. EST ATED DUANTITY OF 3.WAS ANK FILLED WITH -00 TANCE REMAINING INGALLONS INE A7ATERIAL? E]YES [:] NO jMA THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID M DD ( CURRENT LOCALAGENCY F ILITY ID M APPROV D SY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMITAPPROVAL DATE PER IT EXPIRATION DATE CHECKX PERMIT AMOUNT RCHARGE AMT. FEE CODE RECEIPT BY. FORMBB-29-88) THIS FORM MUST BE ACCOMPANIED ACILITY/SITE APPLICATION, FORM 'A,UNLESS C19WNT FORMA' HASBEENFILED DATA PROCESSING COPY