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STATE OF CALIFORN" WATER RESOURCES CONTR'__'BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT-APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING IN RMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK - ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED laq7 FACILFTY/STTE NAME WHERE TANK IS INSTALLED: 35,E gry FARM TANK-YES I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID p B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 3� , II. TANK CONTS IF(A.1) IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. Ek<MOTOR VEHICLE FUEL ❑2 PETROLEUMC. ❑ 1 UNLEADED ❑ 2 LEADED IE EEL B. ❑ 3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑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.p C.A.S.p: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,&D A TYPE OF ❑1 WALLED ❑3 SINGLE WALLED WITH L7 IDR LINES 95 UNKNOWN SYSTEM Lff2 SINGLE WALLED 4 SECONDARY CONTAINMENT ❑99 OTHER - 1 STEEUIRON ❑2 STAINLESS STEEL 3 FIBERGLASS ❑4 STEEL CUD W/RBERGUSS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 PDLYVINYL CHLORIDE5�95PUNEl MF-18100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE � 10 GALVANIZED SMN 99 OTHER ❑ 1 RUBBERUNED ❑2 ALKYD LINING ❑ 3 EPOAYUNING ❑4 CU ING C. INTERIOR UNING ❑5 GLASS UNING ❑ 6 UNLINED m UNKNOYpI _ ❑ IS UMNG MATERIAL COMPATIBLE WITH IGD%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑1 POLYETHLBIE WRAP ❑2 TAR OR ASPHALT ❑3 W ❑4 RBERGLASSREINFORCEUPLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑99 OTHER _ IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,Mom IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 5 U A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALIJ=D A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 95 UNKNO U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLWIWLCHLORIDE(PVC) A U 4 RBERGLASSPIPE A U 91 NONE G MATERIAL A U 5 ALUMINUM A U E A U 7 STEEL CLAD W/FRP A U 8168%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A95 UNKN 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 B iVISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P S 4ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E]VES ❑ NO _ 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 p JURISDICTION p AGENCY p FACILITY I p TANK ID 0 - r =NAME tn!C PHONE 4 WITH MEA CODE PERMIT APPROVAHARGE AMT. PT4 BY: FORM B I6-29-88L THIS FORM MUST BE ACCOMPANIED BY A F...,,LITY/SITE APPLICATION, FORM `A',UNLESS A CURREh, FORM'A' HAS BEEN FILED DATA PROCESSING COPY