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STATE OF CALIFORN WATER RESOURCES CONTRL JOARD 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 3 RENEWALPERMIT ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT FACILITY/SITE NAME WHERE TANK IS INSTALLED: 33 I. TANK DESCRIPTInPi 0 5 CHANGE OF E]6 TEMPORARYNFORMATION TANK ANK CLOSURE ❑7 PERMANENTLY e TANK REMOVEDCL $E_ �/ /L,.E, FARM TANK -VES �NC�/Oa an encn.m. A. OWNERS TANK ID a / S. MANUFACTURED BY: K C. YEAR INSTALLED (�. �� D TANK CAPACITY IN GALLONS' TAAIV l�/1AITru Tn __ A. i MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. 1 UNLEADE 2 LEADED ❑3 DIESEL 3 CHEMICAL PRODUCT E]4 OIL 1 PROD4 GASAHOL 5 JET FUEL ❑ 6 AVIATION GAS Till 5 HAZARDOUS BO 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. M III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A. B. C. 8 D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER 95 UNKNOWN SYSTEM F� 2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER U 95 UNKNOWN I STEEL/IRON 2 STAINLESS STEEL 0 3 FIBERGLASS 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE E] 6 POLYVINYLGHLORDE F_� 7 ALUMINUM B 100% METHANOL COMPATIBLE FRP 95 UNKNOWN 9 BRONZE E]10 GALVANIZED STEEL ` E2 UNKNOWN 99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑ 2 AUKYD LINING ❑ 3 EPDXY LINING 4 PHENOLICUNING LINING ❑ 5 GLASS UNING ED 6 UNUNED A �5 U1NKNGWN /C 5 ALUMINUM ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO F OTHER u D. CORROSION ❑ 1 POLYETHLENEWRAP 2 TAR OR ASPHALT 03 VI WRAP 4 FlBEAGUSS �INFOPCED PLASTIC PROTECTION 5 CATHODIC PROTECTION 91 NONE UNKNOWN D 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND_ BOTH IF APPLICARLF A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINE TRENCH A U 91 NONEU 95 UNKNOWN A U 99 OTHER BY: A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM AA U 7 STEELCLADW/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A 5 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR 8 FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. B 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURETESTING ONE P 8 95 UNKNOWN P 8 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 TANK ID # 101(0101/1 SUBSTANCE REMAINING IN INERT MATERIAL? E_ YES E_ NO APPROVED BY NAMEYIQ I 1p-olkri GALLONS PERMIT 14UMBER THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPUCANTS NAME (PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY # 3� JURISDICTION # AGENCY # FACILITY ID # 00 7 1 TANK ID # 101(0101/1 CURRENT CAL AGENCY FA ILRY IDt 33 APPROVED BY NAMEYIQ I 1p-olkri PHONE WITH AREA CODE PERMIT 14UMBER PERMIT APPROVAL DATE I I FOURMIT EXPIRATION DATE CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT # BY: FORM B (5 -29 -BB) TNq FORM MUST BE ACCOMPANIED BYA FACILITY/SITE APPLICATION, FORM 'A', UNLESS A CURRENT FORMA' HAS BEEN FRED DATA PROCESSING COPY ;e-- 10 10