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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM " TANKTANK PERMIT APPLICATION INFORMATION Z COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. IQ MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED NK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE [L],Y'fANK REMOVED O FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO CA r I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY N A. OWNERS TANK ID# B. MANUFACTUREDBY: GL/� C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: D II. TANK WNTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D A P�fl MOTOR❑3 CHEMICAL PIRODUCTL ❑ 4 O�ROLEUM B 1 PRODUCT C ❑ 1 UNLEADED 2 LEADED E] 3 DIESEL ❑4 GASOHOL ❑ 5 JET FUEL ❑8 AVIATION GAS ❑5 HAZARDOUS E]80 EMPTY E] 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&C.A.S.# lytq C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM V 2I'NGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER �'/S1 STFEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM F-18100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 P ENOLIC LINING UNING 6 UNLINED LINING ❑ S LINING MATERIAL COMPATIBLEITH 100%METHANOL? YES NO �THERWN D. CORROSION ❑ I POLYETHLENEWRAP ❑2TAR OR ASPHALT ❑3 WNYLWRAP ❑ 4 FIBERGLASS REINFORCED PLASRC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE �NKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNO, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE AU SUCTION A U 2 PRESSURE A U 3 GRAVITY -A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U YSINGLEWALLED 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 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FISERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U B CONCRETE A U 7 STEELCLADW/FRP A U 8100%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 s i VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P B 7 PRESSU RE TESTING S 91 NONE P B 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTL CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH H / SUBSTANCE REMAINING IN �LDrn 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# JURISDICTION# AGENCY# FACILITY ID# TANK ID# o �il lololo157 CURRENT LOG AGENCY FACIL ID# APPROVEDB/Y NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE / LCECK PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT BY: b FORM B(6-29-ee) THIS FORM MUST BE ACCOMPANIA FACILITY/SITE APPLICATION, FORM 'A',UNLESS A-wKRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY