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f STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION " ' TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INfFpRMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT F73 RENEWAL PERMIT CHANGE OF INFORMATION El 7 PERMANENTLY CLOS ONE ITEM 2 INTERIM PERMIT ❑4 AMENDEDPERMIT ❑66 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED r FACILITY/SITE NAME WHERE TANK IS INSTALLED: '� Ci[G{/ FARM TANK-YES❑ N ❑ 0 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY gs� A. OWNERS TANK ID# �- B. MANUFACTURED BY: ' W C. YEAR INSTALLED D. TANK CARA---IN GALLONS: O D � II. TANK qONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. i MOT F VEHICLE FUEL ❑2'PETROLEUMB. C. ❑ 1 UNLEADED LEADED ❑3 DIESEL 3 CHEMICAL PRODUCT 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS 80 E 5 HAZARDOUS EMPTY ❑ 95 Up ❑ / ;KNOWN E]2 WASTE ODE 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) ❑ ❑80 E D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF J HAZARDOUS SUBSTANCE STORED 8,CA.S.# CA.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A. TYPE OF ❑ 1 ABLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN �` SYSTEM IWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER E!T" STEBUIRON ❑2 6TAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE E]6 POLYVINYLCHLORIDE ❑7 AWMINUM F-18 100%METRANOLOOMPATIBLEFRP ❑ 9 BRONZE ❑TO GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ LICUNING C. INTERIOR LINING ❑5 GLASS LINING ❑6 UNLINED 5 U OWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%MMMOL? E]YES [11NO OTHER D. CORROSION ❑ I POLYETHLE7IE WRAP ❑2 TAR OR ASPHALT ❑3 VI P ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U "OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U B CONCRETE A U 7 STEELCLADW/FRP A U 8 IOD%METHANOLCOMPATIBLEFRP 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. j P S I VISUALCHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER 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 IMO/VRI 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH GALLONS SUBSTANCE REMAINING IN 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 6 SIGNATURE) DATE q LOCAL AGENCY USE ONLY COUP# JURISDICTION# AGENCY# FACILITY ID# TANK ID# = = I, Y' 1 of L- 6 U 7i CURRENT LOCAL AGENCY FA I L 10# G�C//✓1 / OAPPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER / PERMIT APPROVAL DATE PERMIT EXPIRATION DATE //I ^ r,/: .1 / S __-/000Y/y CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIMY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED _^/'•/S DATA PROCESSING COP"