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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION tt" COMPLETE A SEPARATE FORM WITH THE FOLLOWING INF ATION FOR EACH TANK. _ MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT -/CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED fin FACILITY/SITE NAME WHERE TANK IS INSTALLED: ` Z4U4,FARM TANK-YES❑ NO ^7 � I 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 1 A. OWNERS TANK ID# U L 4'jt- le35D C1 ED BY: U r/(+ C. YEAR INSTALLED S D. TANK CAPACITY IN GALLONS: s6v II. TANK CONTENTS IF(A.1),IS ARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. T"„ MOTOR VEHICLE FUELPETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED IESEL*z 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATIONTGAS ❑ 5 HAZARDOUS ❑ 80 EMPTY Lj 95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# CA.S.#: N . .111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,d D A.TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 12<UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER I ❑ 1 STEBUIRON ❑2 STAINLESS STEEL FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B TATEfl1AL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE F-] 7 ALUMINUM L]8100%METHANOL COMPATIBLE ERP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING n 4 P<NOUC UNING C. INTERIORrL-�1 LINING ❑ 6 UNLINED 9/5 GLASS LINING ❑ 5 UNKNOWN ❑ 6i LINING MATERIAL COMPATIBLE WITH IOD%METHANOL? ❑YES 10 ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑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 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A Ml SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER Aa i STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 5 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%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. P_ 1 VISUAL CHECK O S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS 8 4 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS '�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(MO/YR) 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH N SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# o I o I U 1 CURRENT LOCAL AGENCY FACILITY IDN APPROVED BhY N ME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PE IT EXPIRATIOX DATE N CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTt BY: FORM B(3-7 BB) THIS FORM MUST BE ACCOMPANIEudY A FACILITY/SITE APPLICATION, FORM 'A',UNLEssAwREN FORMA' HAS BEEN FILED DATA PROCESSING COPY