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STATE OF CALIFORNF 7 WATER RESOURCES CONTI. '. BOARD FORM `B': UNUtRGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION -COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY UV 1 NEW PERMIT 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY lNK ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED10 i FACILITY/SITE NAME WHERE TANK IS INSTALLED: () N,r ,yj FARM TANK-YES❑ NO -7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY I� A. OWNERS TANK ID X lo�"' B. MANUFACTURED BY. C. YEAR INSTALLED •lig 06 D. TANK CAPACITY IN GALLONS'. Z Alb II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. F� A_ ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMe. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT n;�4 OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑5_JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN 0'2 WASTE ❑7 METHANOL �99 OTHER(DESCRIBE IN ITEM D,BELOW) 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF JQ HAZARDOUS SUBSTANCE STORED&C.A.S.P wortu crt-: , C.A.S. .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A. TYPE OF [_] l DGUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER I STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS F-14 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL F-15 CONCRETE E]6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING 5�16 UNUNED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE MM 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYERILENE WRAP ❑2 ,T�l OR ASPHALT ❑3VINYL WRAP F-14 FIBERGLASS REINFORCEDPLASTIC PROTECTION ❑5 CATHDDIC PROTECTION LL,411 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNOE ROUND,BOTH IF APPLICABLE A SYSTEM TYPE A I SUCTION A U 2 PRESSURE A U GRAVITY A U 99 OTHER B.CONSTRUCTION A U SINGLE WALLED A U 2 DOUBLE WALLED A 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUMA 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U 95 UNKNOWN A U 99 OTHER Y. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 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 1. ESTIMATED DATE LAST�USED(MO/YR) 2. ESTI T OOUANTITY OF 3.WAS NK FILLED WITH B REMAINING IN R TERIAL? [:]YES ❑NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOW EDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY tl JURISDICTION N AGENCY P FACILITY ID# TANK ID a o Z 3I do lo I 3 CURREN yCAy AGENCY FACILITY ID k AP R�E NAMFjI PHONE M WITH AREA CODE PERMIT NUMBER (,(IL PER IT ROVE D""A PERMIT EXPIRATION DATE �l— CHECK M PERMIT AMOUNT I SURCHA GEA T. FEE CODE RECEIPT X BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED---Y A FACILITY/SITE APPLICATION, FORM `A',UNLESS A-V ARENT FORMA' HAS BEEN FILED DATA PROCESSING COPY