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, gii.S.At is-4w j „Vitkeiikkelr sanufg,N, ''',Wt"r9F* STATE OF CALIFORNIA WATER RESOURCES CONTROL RD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMP TE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. I I 1 NEW PERMIT 7 3 RENEWAL PERMIT 2 INTERIM PERMIT I I 4 AMENDED PERMIT FACILITY/SITE NAME WHERE TANK IS INSTALLED: I ce,v FARM TANK-YES I I NO I I I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN — SO SPECIFY A OWNERS TANK ID # C. YEAR INSTALLED / OC MARKED COMPLETE ITEM D. I Ft PM I %.• IN I G I 11 i •7 ,....,r/Wa 95 UNKNOWN B. PRODUCT 2 WASTE I 1„../(li"INLEADED 7 4 GASAHOL 7 METHANOL 2 LEADED I I 3 DIESEL 7 5 JET FUEL I 1 6 AVIATION GAS 99 OTHER (DESCRIBE IN ITEM D, BELOW) A. I 1 MOTOR VEHICLE FUEL I I 2 PETROLEUM I I 3 CHEMICAL PRODUCT 4 OIL I I 5 HAZARDOUS 80 EMPTY D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED & C.A.S. # C.A.S. F. TYPE OF SYSTEM 7 1 DOUBLE WALLED 12 SINGLE WALLED 7 3 SINGLE WALLED WITH EXTERIOR LINER 4 SECONDARY CONTAINMENT I I 95 UNKNOWN 7 99 OTHER TANK MATERIAL I 1 STEEL/IRON I 5 CONCRETE I 9 BRONZE T7 2 STAINLESS STEEL I 16 POLYVINYL CHLORIDE I I 10 GALVANIZED STEEL I I 3 FIBERGLASS 7 7 ALUMINUM 1 I 95 UNKNOWN I J 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC 1 18 100% METHANOL COMPATIBLE FRP 199 OTHER I INTERIOR LINING I 1 RUBBER UNED 7 2 ALKYD LINING .1 5 GLASS LINING 1 I 6 UNLINED 7 IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL'? I I 3 EPDXY LINING I I YES I I NO 1-1 4 PHENOLIC LINING 95 UNKNOWN 99 OTHER CORROSION PROTECTION j 1 POLYETHLENE WRAP 5 CATHODIC PROTECTION 12 TAR OR ASPHALT 91 NONE [ I 3 VINYL WRAP 7 95 UNKNOWN 4 FIBERGLASS REINFORCED PLASTIC 99 OTHER j IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE AU 1 SUCTION A 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 A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100% 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. S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE MARK ONLY ONE ITEM MANUFACTURED BY: TANK CAPACITY IN GALLONS: /j f(9() et_e 7 5 CHANGE OF INFORMATION I I 7 PERMANENTLY CLOSED T -1 6 TEMPORARY TANK CLOSURE I 8 TANK REMOVED to C.T1 N.) CT) CO i" III A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A Ii 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION C. MATERIAL GALLONS 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN 3 WAS TANK FILLED WITH INERT MATERIAL? I YES j NO 1 ESTIMATED DATE LAST USED (MO/YR) 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 # 3 TANK ID # PHONE N WITH AREA CODE APPROVER BY NA LJ PERMIT EXPIRATION DATE PERMIT APPROVAL DATE flO cc). CURRENT L CAL AGENCY FACILITY ID N PERMIT NUMBER BY: EIPT N FEE CODE PERMIT AMOUNT SURCHAR E MT. /Y0 1 CHECK N FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIED BY A PAZ1LITY/SITE APPLICATION FORM 'A', UNLESS A CURRENT FORM 'A' HAS BEEN FILED nj,T.ft eartrESIIND nnpy