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STATE OF CALIFORNIWATER RESOURCES CONTRC `OARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM P TANK Clc-CMPLETE TANK PERMIT APPLICATION INFORMATION e�A SEPARATE FORM WITH THE FOLLOWIN 596ORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT EEf5 CHANGE"INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM F-12 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 'j�o?(p$" �, Cpm ZL FARM TANK-YES O ❑ 0 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: a4 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: O 11. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. CA A. 52'1MOTOR VEHICLE FUEL; ❑2 PETROLEUMC. ❑ 1 UNLEADED LEADED ❑ 3 DIESEL ❑I 3 CHEMICAL PRODUCT ❑4 OIL B. 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL E] 6 AVIATION GAS IJ 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 HAZARDOUS SUBSTANCE STORED&C.A.S.IN C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,a D A.TYPE OF ❑ 1 DOUBLEWAUED ❑ 3 SINGLE WALLED WITH OTERIOR UNEfl EKUNKNOWN SYSTEM ❑ 2 SINGLEWAU.EO ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 MEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 A MINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHFA CONING LINING F-15 GLASSUNING F-16 UNUNEO UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VI WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE L&f 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IFUNDERGROUNO,BOTH IFAPPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 95 ONKN W A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 5 UNKN 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 ALUMINUMA U 6 CONCRETE A U 7 STEELCLAOW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 95 UNKNO 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 8 IVISUAL CHECK P S 2 INVENTORY RECONCILIATION P B 3VADOSE WELLS P 8 TRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S PRECISION TESTING P 6 7 PRESSURE TESTING P S 91 NONE P C95 UNKNOW P S 99 07HER 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 INERT MATERIAL? ❑YE$ ❑ NO j GALLONS 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# 3 y 0 10N 3 3 o o a / LERMITNUMBER AL AGENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE pECEIPT# BY: FoRr. B(6-2 THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION FORM 'A' 'A' HAS BEEN FILED UNLESS A CURREA JRMI CD DATA PROCESSING COP" 1Q( 7-� _