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STATE OF CALIFORNIA& WATER RESOURCESCONTRO#ARD FORM 'B': UNDE ROUND STORAGE TANK PRO AM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. a� MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT DS'CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED T K ONE ITEM F-1 F72 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE .A TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: N =!j� M WTt5CAFARM TANK-YES❑ NO Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 A. OWNERS TANK ID B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: G O W 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,9OMPLETE ITEM ON A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B C. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL N ❑ 3 CHEMICAL PRODUCT ❑ 4 OILPRODUCT ❑ 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&G.A.S.# IV CA.S.4: A//)e- All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASSEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER \n 1 RUBBER LINED ❑ 2 AL LINING F-13 EPDXY LINING ❑ 4' LINING C. INTERIOR ,uCi r LINING SGLASS LINING UNLINED .,vIOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ES ❑ NO 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑ 2TAR OR ASPHALT ❑ 3 P RAP FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE - .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(Lq 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A 3 LINED TRENCH . A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE IPVC) A U FIBERGLASS PIPE C. MATERIAL A U 5ALUMINUM A U.,6 CONCRETE A U 7STEEL CLAD W/FRP A B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL -� a 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. w/I P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLSPOS 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LA T 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY V/S NAME, PHONE#WITH AREA CODE r� PERMIT NUMBER PERMIT APPROVOILDAT PERMIT EXPIRATINDATE CHECKp PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTBY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANI A FACILITY/SITE APPLICATION, FORM 'A',UNLESS AWNT FORMA' HAS BEEN FILED DATA PROCESSING COPY