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STATE OF CALIFORNIA WATER RESOURCESCONTROI 'BOARD FORM 'B': UNDEFtiROUND STORAGE TANK PROOF-tAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY Cl-0;Fj ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED 09 FACILITY/SITE NAME WHERE TANK IS INSTALLED: 5 , , I FARM TANK-YES❑ NO z Z 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I� A. OWNERS TANK ID# v 8. MAN TURED BY: C. YEAR INSTALLED I D. TkAXAPAC1_710ALOSSSbo. II. TANK CONTENTS IF(AA),IS MARKED,COMPLETE ITEM C.IF(A.t),IS NOT MARKED,COMPLETE ITEM 0. Ln A, D�rl MOTOR VEHICLE FUEL ❑2 PETROLEUM B. Ap L V1 UNLEADED ❑2 LEADED ❑ 3 DIESEL41 µ ❑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 D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF ' HAZARDOUS SUBSTANCE STORED 8 C.A.S.# C.A.S.#: AIIA XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A. TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CIAO W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-] 1 RUBBER LINED ❑ 2 ALKYD LINING F-] 3 EPDXY LINING F-14 PHENOLIC LINING LINING ❑ 5 GLASS LINING �8 UNUNED ❑95 UNKNOWN ❑ IS UNWG MATERIAL COMPATIBLE WITH 100%METHANOP ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑2TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION Eg4 NONE - ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A LA I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A SINGLEWALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER AV STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/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. ITt P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS VN'- P S 6 PRECISION TESTING P 3 1 PRESSURE TESTING1 NONE P S 95 UNKNOWN P 13 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATEST USED(MO/YR) 12. ESTIMATED O ANTITY OF 3.WAS TANI FILLED WITH SUBST C E INING IN ONS IN IAL? ❑YES ❑ NO 141 1 OA{ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF FIERJURY,AND TO THE BEST OF MY KNO WLE GE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK 10# [f�l 10D 1 l 1= 1010161 CURRENT LOCAL AGENCY FACILITY 10 APP VED NAME PHONE#WITH AREA CODE 30 F Ak PERMIT NUMBER PERMIT APPROVAL PERMIT EXPIRATION DATE CHECK M PERMIT AMOUNT I SURCHARGE AMT. FEE CODE _RECEIPT# BY: UI i FORM B(3-7-SB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED