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STATE OF CALIFORN01 WATER RESOURCESCONTP BOARD FORM 'B': UNDiiRGROUND STORAGE TANK PROGRAM m" TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z 10 MARK ONLY 2"I'NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLYCL ONE ITEM [-] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED:/T? -s' FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-UIPECIFY N A. OWNERS TANK ID N D 1 B. MANUFACTURED BY: aAA,aW C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. 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 PETROLEUM �B. C. k�ll UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL IJ ' 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 J HAZARDOUS SUBSTANCE STORED&C.A.S.N C.A.S.tl: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM Lif SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER Ej 1 STEELARON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CAORDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑93'GNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GUSSUNINGUNLINED ❑ 95 UNKNOWN -• J ❑L$UNING MATERIAL CCMPATIBLE WITH IOD%METHANOL? ❑YES ❑ NO @E�'99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP '2TAR OIL ASPHALT ❑ 3 VIRYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMAT ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE CTI A. SYSTEM TYPE A 1 SUON A U 2 PRESSURE A 'U 3 GRAVITY A 'U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A 60SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 9/ 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 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%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. SP S 1 VISUAL CHECK P' S 2 INVENTORY RECONCILIATION P B 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P & 5 GROUND WATER MONITORING WELLS �- P 6 PRECISION TESTING P S 7 PRESSURE TE STING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED ATE LAST USED(MO/YR) 2. ESTIIVATEDAUANTIFY OF GALLONS 3.WAS NK FILLED WITH SUBS A MAINING IN ATILLED E]YES ❑ NO j THIS F RM HAS BEEN COMPLETED UNDER PENAL TY 6F PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N = lololo I ! CURRENJJT��LOCAL AGENCY FACILITY ID N APPROVED BY ME`s �/( PHONE N WITH AREA CODE 6b A�1 '! 2.J Cl PERMIT NUMBER PER7T ATPD V DATE PERMIT EXPIRATION DATE !/ 2r � (T- CHECK N PERMIT AMOUNT 8URCHARGE AMT. FEE CODE RECEIPT* BY: FORM a(6-2966) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS MRRENT FORMA' HAS BEEN FILED \,\/l