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..t STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD • FORM B': UNDERGROUND STORAGE TANK PROGRAM ' -TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1 NEW PERMIT 1 ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM 02. 1 1 N yEPIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES E ] NQS I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOW -SO SPECIFY ` I O A. OWNERS TANK ID# B. MANUFACTURED BY: d r C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Z. f d' W 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. Ell-1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. / C. �GNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT E] 4 OIL E 'RODUCT ❑ 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&C.A.S.# C.A.S.#: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF LLQ" BLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON 2 STAINLESS STEEL BERGLASS ❑4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL ❑ 5 CONCRETE F-] 6 POLYVINYLCHLORIDE ❑7 ALUMINUM E]8 100%METHANOL COMPATIBLE FRP } ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F] 1 RUBBER LINED F-12 ALXYO LINING ❑3 EPDXY LINING ❑4 PHENOLIC UNI NG LINING ❑ 5 GLASS LINING E4—LINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP [L�tfIBERGLASS REINFORCED PLASTIC PROTECTION E:] 5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN -]99 OTHER t IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A PRESSURE 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 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE(PVC) A l�4 FIBERGLASS PIPE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP 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 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLZ!523 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 3 7 PRESSURE TESTING P 8 91 NONE P S 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? ❑YES [:] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OFPERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLITS ME(/�SIGNA GATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION M AGENCY k FACILITY ID N TANK ID# 1YR] I I I j E[ I I L [ 1,1 / o CURRENT LOCAL AGENCY FACILITY ID 0 APPR O BY NAME / PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT 0 BY: FORM B(3-7 88} THIS FORM MUST BE ACCOMPANI ,B A FACILITY/SITE APPLICATION, FORM'A',UNLESS RENT FORMA' NAS BEEN FILED t DATA PROCESSING COPY