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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION a COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT IY5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO o K X17 ONE ITEM ❑2 INTERIM PERMIT F-14 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED I ' [� 1 FACILITY/SITE NAME WHERE TANK IS INSTALLED: 'y{J 5� �yL, '(� �— FARM TANK-YE8❑ NO w I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY Ca A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: ALIO O II. TANKCONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. [gl MOTOR A F-1 3 C EMICAL PIRODUCTL ❑ 4 OIL PETROLEUM B 1 PRODUCT C ❑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.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ DOUBLE WALLED F—] 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 12 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEUIRON ❑ 2 STAINLESSSTEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. MATERIAL TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17.$IEUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN. ❑99 OTHER ❑ i RUBBER LINED ❑2ALKYD LINING ❑ 3EPOKY LINING ❑ PHENOLIC LINING C.INTERIOR IN N�R ❑ 5 GLASS UNING ❑6 UNLINED R UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO f/99 OTHER VI- D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TARORASPHALT ❑ 3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC I PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE Y UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN 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 14 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 A U 91 NONE C. MATERIAL A U 5 ALUMINUM A PI46 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A N/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 8 1VISUAL CHECK 0 8 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 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 OF3.WAS TANK 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. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID If TANK ID# E3al = = 10101f o ! o I 01011 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAM PHONE x WITH AREA CODE Sh D 5 - -8 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE I REfEIPT0 BY: FOHM6(6-29-ee) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A!,UNLESS A. REM FORM HAS BEEN FILED S DATA PROCESSING COPY