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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATIONm COMPL TE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑i 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT /� E:] 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 01 FACILITY/SITE NAME WHERE TANK IS INSTALLED: S• Ohme or Q,Akl(!C,_ FARM TANK-YES❑ NO Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY iO A. OWNERS TANK ID# )11 I B. MANUFACTURED BY: n C. YEAR INSTALLED } C I D. TANK CAPACITY IN GALLONS: 5 W II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),ISNOT MARKED,COMPLETE ITEM D. A. i MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑/OIL PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑M 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 d C.A.S.# L pl- C.A.S.#: Aj) IL XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C,&D A. TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM ❑2 SINGLE WALED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC I.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUM M ❑ 8 111%METHANOL COMPATIBLE FAP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4PH UNING LINING ❑5 GLASS LINING ❑8 UNLINED UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 160%METNANOL? ❑YES ❑NO ❑99 OTHER D. PROTECTION [—]5 CATHODIC PROTECTION E:]91T3 V NONE ASPHALT ❑ UNKNOWN 99 OTHERREINFORCED PLASTIC ASS IV. PIPING INFORMATION CIRCLE IF ABOVE GROUND, U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A Cd r7 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 11 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A G95 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 1 VISUAL CHECK 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P PRECISION TESTING P 8 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK,PILLED WITH ' N /� SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑NO THIS FORM HAb BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION k AGENCY# FACILITY ID# TANK ID# CURRENTLO L AGENCY FACILITYID# APPROVED BY MINE PHONE WITH AREA CODE ,✓' ZZ PERMIT NUMBER PERMIT APPROVAL P RMITEXPIRA DATE DATE/ CHECK# PERMIT AMOUNT SURCHARGEA FEE CODE RECEIPT BY: �1\ FORM B(3-7-m) THIS FORM MUST BE ACCOMPANIED' Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A`CORRENT FORMA' HAS BEEN FILED W� .lwJ r'..