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STATE OF CALIFORNI'\ WATER RESOURCES CONTR" BOARD FORM `B': UNDts2GROUND STORAGE TANK PRCYGRAM '= TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z Ib MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 RMANENTLY CLOSED TANK ONE ITEM F--] 2 INTERIM PERMIT F--] 4 AMENDED PERMIT E-] 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED a N FACILITY/SITE NAME WHERE TANK IS INSTALLED: S1115 21( k FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 'J A. OWNERS TANK IDN M.L B. MANUFACTURED BY: the C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Q II. TANK PONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM A 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL 1 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 HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF F-I/DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM og 2 SI LE WAU.ED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 MORON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCREFE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑81 DD%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZEDSTEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR [—] I RUBBERUNED ❑ LKYD LINING ❑3 EPDXY LINING ❑ 4 PHENOLIC UNING LINING ❑ 5 GLASS UNING 6 AUNUNED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 10D%METHANOL? ❑YES ❑NO ❑ 99 OTHER D. CORROSION ❑ LYETHLENEWRAP ❑2 TARORASPHALT ❑3 VINYL WRAP E]4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODICPROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMAT ON CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A(I64 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A m 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER ALW 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 1 DO%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER EAK DETECTIO SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 4 A, P S 1VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS PIS 6 PRECISION TESTING P S 7 PRESSURE TESTING 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 FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? GALLONS ❑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# [Eil ITYEM 10 10 ) I:� CURRENT LOCAL AGENCY`�/�/FA�ILITY IDN APPROVED BY NAME PHONE X WITH AREA CODE PERMIT NUMBER 1 PERMIT APPROVAL DATE PERMIT""RATION DATE CHECK X PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# 01 FORM B(6-29-eel THIS FORM MUST BE ACCOMPAIaED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED ;TNG COPY