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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM Go TANK ,TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING IN MATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑O RENEWAL PERMIT &5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ I AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑S TANK REMOVED U 9 FACILITY/SITE NAME WHERE TANK IS INSTALLED: /u I FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A OWNERS TANK 10 I B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CPNTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,CO ITEM D. A E21'MOTOR VEHICLE FUEL ❑2 PETROLEUMC. UNLEADEO L]2 LEADED C-]S DIESEL B. ❑0 CHEMICAL PRODUCT ❑I OIL 1 PRODUCT ❑ 1 GASAHOL ❑ 5 JET NEL ❑ 0 AVIATION OAS ❑5 HAZARDOUS ❑00 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 1 METHANOL ❑ 99 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED A C.A.S.I CA.S.I: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.0.C,i D A TYPE OF ❑ I W ❑0 SINGLE WALLED MIN EXTERIOR LNER ❑95 UNNoww SYSTEM 2 SI WALLED ❑ 1 SECOWNCONTMWNT ❑ 99 OTHER 1STEEU" ❑2 STAINLESS STEEL ❑2FIBERGLASS ❑ 1 STEEL CAD WIFIBUICA$S REWORCED PLASTIC e.TANKF-1s mnDErE ❑e Parv9m DLGRGE ❑ 1 ALUMINUM E] 1100%METWOLCOWATOLEFRP MATERIAL ❑9 MZE ❑ 10 GALVANIZEDSTEEL ❑95 UNKNON ❑99 OTHER C INTERIOR ❑ I AUB0ER l0IE0 ❑ LW NG ❑2 EPDXY UNNG ❑/PHENCLICUNINO LININO ❑ 5 � I IIUNEO ❑95 UNKNOWN ❑BUMNGMAnfMCOWAPMMTHIOD%METIMNOL2 ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYETHLEWWRAP ❑2 TARORASPHM.T ❑ 3 VnAFO- ❑ 1 RBERGLASSREWORCFDPILMTK: PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE E34uwmm ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U B GRAVITY A U 91 NONE A U S U N U 99 OTHER 0.CONSTRUCTIONA U I SING D A U 2 DOUBLE WALLED A U 7 LINED TRENCH A U 91 NONE A 95 UNKNOWN U 99 OTHER A U TEEL/Ifl A U 2 STAINLESS STEEL A U 9 POLYVINYL CHLORIDE(PVC) A U I FIBERGLASS PIPE A U 9f NONE G MATERIAL A U S ALUMINUM A U 8 CONCRETE A U T STEEL CLAD W/FRP A U 8 1(0%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 t ( VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P t 3VADOSE WELLS P t 1 ELECTRONIC MONITOR P 6 5 GROUND WATER MONITORING WELLS t. 8 PRECISION TESTING P t / PRESSURE TESTING ► - P • 95 UNKNOWN P t 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 0.WAS TANK FILLED WITH SUBSTANCE REMAINING IN _ GALLONS INERT MATERIALT ❑YES 0 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNAL URE) DATE LOCAL AGENCY USE ONLY COUNTY I JURISDICTION P AGENCY I FACILITY ID E TANK ID/ 3 c Ll --1 -71 .;f 1 CURRENT LOCALAGENCY FACILITY ID 1 APPROVED BY NAME PHONE E WITH AREA CODE /'77 L)13/L &'j PERMIT NUMBER PERMITAPPROVAL DATE PERMIT EXPIRATION DATE ✓ J \`�� CNECKI PERy1T AMOUNT ARGE AMT. FEE CODE R C TI