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„� Sr}- '•l '�iT �yj. .,�Y,.w,<'�"' ..,tl ✓'': Ir ”. r-h;4' 3i` �i""_i; R_. STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ° • -FbRM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION SCOMMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. °•,,;:�`� MARK ONLY EG ryEW PERMIT ❑3 RENEWAL PERMR ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNO A► --SO SPECIFY I A. OWNERS TANK IDN B. MANUFACTURED BY: I -n C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: I-� 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(a1),IS NOT MARKED,COMPLETE ITEM D. }-a A. ❑>40TOR VEHICLE FUEL ❑2 PETROLEUM B. C. FLI�-VNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL EZPr ODUCT ❑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 8r C.A.S.# C.A.S.#: x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A Ley TYPE OF BUE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER :❑❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEWIRON ❑2 STAINLESS STEEL [9.PIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC 6.TANK MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 10091 METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXY LINING ❑4 PHENOLIC UNING C.INTERIOR LINING ❑5 GLASSUNING EDApIiRUNED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP [ZIA ABERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 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 RESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A DOUBLE WALLED A U 3 LINED TRENCH 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<i*FIBERGLASS PIPE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 6 100%METHANOL TMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER 7 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 8 2 INVENTORY RECONCILIATION P 8 3 VAOOSE WELL KV 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTfNG P S 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? E-]YES E]NO ' THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS E(P ED 6 SIGNATU_R n /��_� DATE Com` _ -ZS" LOCAL AGENCY USE ONLY COUNTYV, JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME 7 PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# DY: 1' FORM B(3-74mg THIS FORM MUST BE ACCOIiPAN1 A FACILITY/SITE APPLICATION, FORM'A',UNLI2SS).,.. _ENT FORKW HAS BEEN FILED LOCAL AGENCY COPY