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STATE OF CALIFORNIA WATER RESOURCES CONTROL ')ARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM ' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. G MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 1 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT + ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 1Z FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3535 [. , FARM TANK-YES❑ NO N I � 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY � A. OWNERS TANK IDR 77 B. MANUFACTURED BY: LLQ �I C. YEAR INSTALLED t4D. TANK CAPACITY IN GALLONS: 11. 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 ETROLEUM B. C. ❑ 1 UNLEADED E] 2 LEADED ❑3 DIESEL MICAL ❑3 CHEPRODUCT d4 e01L -❑,# PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY [:]95 UNKNOWN WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL ONTER NAME OF � / v� HAZARDOUS SUBSTANCE STORED&C.A.S.R (NAG / C.A.S.R: LJ III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A.TYPE OF ❑ 1 DOUBLE ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM ❑2 SINGLE WA ❑4 SEGONDARYO MNNMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ i RUBBER LINED 2 ALKYD UNING ❑3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR LINING ❑5 GLASS LINING E24UNUNED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLETEWHAP ❑2 TAR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:]5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GR ND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A, U 2.PRESSU 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 WkED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINUESSST&k A U 3 POLYVINYL CHLORIDE(PVC) A U 4 RBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR ECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P B 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 6 3 VADOSE WELLP 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 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 ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF ASR'KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION N AGENCY R FACILITY ID R TANK ID R DD /R aC3o CURRENTLOOLAGEicyFACILITY IDN APPROVE SY NAME ^ W/� PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE P I MIT EXPIIRATION,D�A•TE G CHECK N 7PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORM B(6-z9-GB) THIS FORM MUST BE ACCOMPANIED FACILITY/SITE APPLICATION, FORM 'A',UNLESS A FORM'N HAS BEEN FILED DATA PRC(:ESSIN( (;OPY