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STATE OF CALIFORNM WATER RESOURCES CONTR' BOARD FORM 'B': UNDERGROUND STORAGE TANK PROtRAM � P TANK TANK PERMIT APPLICATION INFORMATION `m COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z 10 MARK ONLY [--11 NEW PERMIT E]3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION [-]7 RMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED N FACILITY/SITE NAME WHERE TANK IS INSTALLED: 74p3 n 4,j FARM TANK-YES❑ NO CA I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFYpo A. OWNERS TANK IDN B. MANUFACTURED BY: 14L C. YEAR INSTALLED tj D. TANK CAPACITY IN GALLONS: UO Q II. TANK rONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,CqMPLETE ITEM D. A. Eyl MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. EVUNUEADED ❑2 LEADED ❑ 3 DIESEL F-1B.3 CHEMICAL PRODUCT ❑4 OIL 611"PRODUCT [—] 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ SO 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.R C.A.S.R: III. TANK CONSTRUCTION MARK ONE ITEM ONLYIN BOXAB,C.&D A. TYPE OF ❑ I DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM LE WALLED ❑4 SECONDARYGONTAINMENT ❑ 99 OTHER STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WNIBERGUSS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ID GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ I RUBBERUNED ❑PLKYDLINING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR E] 5 GLASS LINING 6 UNLINED ❑95 UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE NTH IGB%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑/poLYErHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYLWMP ❑ 4 RBERGUSSREINFORCEDPLASNC PROTECTION ILCY7Jf 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMA ION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A 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 A U i STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTIO YSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. S 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 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 QUANTITY OF 3.WA STANK FILLED WITH 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY 6 JURISDICTION k AGENCY k FACILITY ID M TANK ID N m 1010- 1 1=$ Co ou CURRENT LOCAL AGENCY F CILITY IDA APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT* BY: IV y FORM B(6-29-ea) THIS FORM MUST BE ACCOMPAWIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLE K CURRENT FORMA HAS BEEN FILED �a DATA PROCESSING COPY