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STATE OF CALIFORNIA WATER RESOURCES CONTRO' 'OARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION G COMPLETE A SEPARATE FORM WITH THE FOLLOWI INFORMATION FOR EACH TANK. QO z MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 10 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 6 TANK REMOVED J 1 W FACILITY/SITE NAME WHERE TANK IS INSTALLED: C r FARM TANK-YES❑ NO (,V {y) I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY � A. OWNERS TANK ID# 3 1 B. MANUFACTURED BY: ,,+�11 CIO C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: /� p- O II. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED, OMPLETE ITEM D. A_ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL �PROOUCT ❑4 GASAHOI ❑ 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&CAS.If C.A.S.W III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,AD A.TYPE OF ❑ USLE WALLED 3 SINGLE WALLED WITH EKTERIOR LINER ❑95 UNKNOWN SYSTEM W 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEURON ❑2 STAINLESS STEEL ❑3 RBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑8 POLYVINYL CHLORIDEUMINUM MATERIAL El MATERIAL OD%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C. INTERIOR rrLLJJdd F-11 RUBBERUNED ❑2 ALKYD LINING ❑3 EPDXYLINING ❑/HENOLICLINING LINING ❑5 GLASS UNING ❑8 UNLINED 95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TARORASPHALT ❑2/w.WRAP ❑4 FIBERGLASS REINFORCED PUSTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE R795 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A VSUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A& >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 U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A&5 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 8 1 VISUAL CHECK GN 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS B 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? �YES [:]NO 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 P JURISDICTION N AGENCY k FACILITY ID k TANK ID 8 do D ol o 103 CURRENT LOCAL M ID N APPROVED BY NAME AGFNCYKACI PHONE N WITH AREA CODE 4�t 6 PERMIT NUMBER -PERMIT APPROVAL APPROVAL DATE PERMIT EXPIRATION DATE \`f1 CHECK X PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT M BY: FORM B I6-29-BBI THIS FORM MUST BE ACCOMPANIMUY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS ACURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY