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STATE OF CALIFORIY WATER RESOURCES CONTF BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM m TANK TANK PERMIT APPLICATION INFORMATION m COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _- Z mc MARK ONLY ❑YNEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CNK ONE ITEM 2INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED O N FACILITY/SITE NAME WHERE TANK IS INSTALLED: H /j .-7� �(�./ FARM TANK-YES❑ NO (j� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# / B. MANUFACTURED BY: �� W C YEAR INSTALLED 0 D. TANK CAPACITY IN GALLONS: OQV 11. TANK/CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM A. 1 MOTOR VEHICLE FUEL F-12 PETROLEUM C. E' 1 UNLEADED 2 LEADED ❑3 DIESEL F-13 CHEMICAL PRODUCT ❑ 4 OIL B PRODUCT ❑4 GABAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS - ❑80 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.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 O A.TYPE OF ❑ OUBLEWALLED F-13 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM LKGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEELIPON ❑2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ENOUC LINING LINING ❑ 5 GLASS UNING ❑6 IINUNED 95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH IOW METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3 LWRAP F-] 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION 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 U-)5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSISTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A pp��6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 I0 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A/U/95 UNKNOWN A U 99 OTHER EAK DETECTION SYSTEM CIRCLE PSV/FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. I. P S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS OS 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 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 GALLONS INERT MATERIAL? ❑YES E] NO ] THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# Ml a a 5 6 1 10 / CURRENT LOCAL AGENCY FACILITY ID• APPROVED BY NAME PHONE x WITH AREA CODE /�RGd S G7/le-5 PERMIT NUMBER PERMIT APPROVAL DA7 PERMIT EXPIRATION DATE i/- 777 CHECK N I SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-8B) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY �-