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STATE OF CALIFORNIA WATER RESOURCE$,CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK �� TANK PERMIT APPLICATION INFORMATION % r COMPLETE A SEPARATE FORM WITH THE FOLLOWINGJN`FORMATION FOR EACH TANK. z FO r MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 216PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 0 9 W FACILITY/SITE NAME WHERE/TANK IS INSTALLED: Ild() / 4��q�,� FARM TANK-YES NO (,V 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Ln W A. OWNERS TANK ID R B. MANUFACTURED BY: d') C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 1100o II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM e. C. ❑ I UNLEADED ❑2 LEADED DIESEL 3 CHEMICAL PRODUCT ❑4 OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM 0,BELOW) U IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.R C.A.S.#: III. TANK CONSTRUCTION NARK ONE ITEM ONLY IN BOX A B,C,a D A TYPE OF ❑ 1 WAS ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER I STFEL/IRDN ❑2 STAINLESS STEEL ❑3 FISMIASS ❑4 STEEL GAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONGETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR 1 RIBBER LINED 2 ALKYD UNING 3 ER(TXY LINING ❑ 4 PH UNING 5 GLASS LINING ❑6 UNUNED UNKNOWN LINING ❑ ❑IS UNING MATERIAL COMPATIBLE WITH 100K METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWMP ❑2 TAR OR ASPHALT ❑3V WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑W OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A IMN- A U 2 PRESSURE A U 3 GRAVITY A U 9/ NONE AC U NK A U 99 OTHER I B.CONSTRUCTION A LA I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 Uf4kNOW A U 99 OTHER A U I STEEL/# A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIB PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U B 100%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. 6 1 VISUAL CHECK i7)8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P B 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES _] NO O16LLON6 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 M AGENCY# FACILITY ID# TANK ID# o 0 I / 0 7I 71 10 1 0 1 d l CURRENT LOCAL AGENCY FACILITY IO# APPROVED BY NAME PHONE#WITH AREA CODE /''// PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CNECKY PERMIT AMOUNT SURCHARGE AMT. FEECODE RECEIPT# BY: C� FORM B(6-z9-ee) THIS FORM MUST BE ACCOMPANIEu b AFACILITY/SITE APPLICATION, FORM 'A',UNLESS A URRENT FORWK HAS BEEN FILED DATA PROCESSING COPY