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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD /.•,,; ...,s FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWALPERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED f1,;r FACILITY/SITE NAME WHERE TANK IS INSTALLED: 935 f f FARM TANK-YES❑ NO ..,� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY O A. OWNERS TANK IDR )tik B. MANUFACTURED BY: U^Ic C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS'. W II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. cy) A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ~ ❑3 CHEMICAL PRODUCT 4 OIL ❑ 1 pq T ❑4 GASAHOL ❑ 5 JET FUEL 6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN EKWASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBf.IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CAS.R "w A&TC-, All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,8,C,&D A. TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEELPRON ❑2 STAINLESS STEEL 7 3 FIBERGLASS I]4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM B TOM METHANOL COMPATIBLEFRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEELKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PHEN CONING LINING ❑ 5 GLASS LINING ❑ 6 UNUNED NKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IW%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑ 2TARORASPHALT ❑3 VIN" AP ❑4 FIBERGLASS REINFORCED PLASTIC !I PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER ti B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 5 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE 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 095 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. n P 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 I' P S 6 PRECISION TESTING P S 7 PRESSURE TESTING 49 91 NONE P S 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 SUBSTANCE REMAINING IN INERT MATERIAL? GALLONS ❑YES ❑ NO ri/PrTHIS FORM AAS 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 R JURISDICTION R AGENCY R FACILITY ID# TANK ID# 10101 1 = I aoa / CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAM NE N WITH AREA CODE I PERMIT NUMBER PERMIT APPROVAL DATE P MIT PIRATION DAty CHECKXPERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# RY: FORM B(3-7 a8) THIS FORM MUST BE ACCOMPANIE7 BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY