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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM 0 TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 0 Z 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE &8 TANK REMOVED N FACILITY/SITE NAME WHERE TANK IS INSTALLED: , FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# Om 2 I B. MANUFACTURED BY: N C. YEAR INSTALLED flk tj I D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. �MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED �` LEADED ❑ 3 DIESEL CHEMICAL PRODUCT ❑4 OIL �pI�II 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS [—]5 HAZARDOUS ❑80 EMPTY [—]95 UNKNOWN U 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A. TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER FP4195 UNKNOWN SYSTEM ❑ 2 SNGLEWALLED ❑4 SECONDARY CONTAINMENT R {T�S�yL,I STEEL/IRON ❑2 STAINLESS BTEEL ❑3 FIBEypSpLASS? 45TEEL CLAD W/FIBERGLASS REINFORCED PLASTIC -. B.TANK MATERIAL N 5 CONCRETE ❑e POLYVINYL CHLOR IDE ❑7 AUIMINUM '- ❑8100%MVHANOLCOMPAPBLEFRP/ ❑ 9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑) C.INTERIOR rfflB R�LJNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PHENOLICUNING f G/ LINING ❑5 LASSUNING ❑B UNLINED � 95 UNKNOWN K/ ❑ IS LINING MATERIAL COMPATIBLE WITH 100%MEIHANOL? ❑YES ❑ NO., X[9901HER Vn D. CORROSION ❑'I POLYETHLENE WRAP ❑2 TAROPASPHALT ❑ 3VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE t® 95 UNKNOWN ❑.W OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IFAPPLICABLE A.SYSTEM TYPE AM SUCTION A U 2 PRESSURE A U 3 GRAVITY ` - A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A(U79 UNKNOWN A U .99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS$TEEL A U 3 POLYVINYL CHLORIDE(PVC) A' U 41FIBERGLASS PIPE 'A U 91 NONE C. MATERIAL A U 5ALUMINUM A 11� CONCRETE A U 7STEEI,CLADW/FRP A U 810M METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A(7�L 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 S I VISUAL CHECK 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS" P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# m = = jojojjj�O 0 p CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE EM' I' 2 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE --- CHECK# PERMIT AMOUNT _ SURCHARGEAMT. FEECODE RECEIPT# BY: FORM B(6-29-36) THIS FORM MUST BE ACCOMPANIC78Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING GQPY