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STATE OF CALIFORNIA' WATER RESOURCESCONtRF" BOARD FORM 'B': UNDLRGROUND STORAGE TANK PRb-dRAM TANK TANK PERMIT APPLICATION INFORMATION (� COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT F-1 3 RENEWAL PERMIT a5 CHANGE OF INFORMATION 1 PERMANENTLY CLOSED TANK 1 O ONE ITEM ❑2INTERIM PERMIT 4 AMENDED PERMIT 8 TEMPORARY TANK CLOSURE ©8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: /O$ N- E 9TY FARM TANK-YES❑ NO N I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY w W A. OWNERS TANK ID R G.�, B. MANUFACTURED BY: Lam. C. YEAR INSTALLED //,K , D. TANK CAPACITY IN GALLONS: �orD 6-4 - II. TANK CONTENTS IF(AL1),10 MARKED,COMPLETE ITEM C.IF(ALT),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL E] 2 PETROLEUM S. C. ❑ 1 UNLEADED 2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT F] 4 OIL PRODUCT ❑ 4 3AASAHM 0 5 JET FUEL 8 AVIATION GAS L]5 HAZARDOUS Ej 80 EMPTY ❑95 UNKNOWN Ej 2 WASTE T METHANOL E]99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED A C.A.S.R C.A.S.R: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑1 DOUBUWALLED ❑3 SINGLE WAILED WITH EXTERIOR LNER %UNKNOWN SYSTEM 2 MOLE WALLED [j 4 MDONDAW OONTAINMENT 99 OTHER I STEELIIRON Ej 2 STAINLESS STEEL 3 FIBERGLASS Ej 4 MMCLAGW/RBEMLASBREINFORCEDPLASRC B.TANK 5 CONCRETE [j 0 POLYVINYLCHLORIDE 7 WIMINUM Ej B 100%METHANOL COMPATIBLE FRP MATEIIIAL 9 BRONZE 10 04VANIZED STEEL %UNKNOWN E]99 OTHER C.INTERIOR ❑ I RIBBER LINED 2 ALKYD LINING ❑3 EPDXY LINING [-]4ENENOUC LINING LRRNB ❑5 GLASS LINING 0 UNLINED 95 UNKNOWN Ej S LINING MATERIAL COMPATBLE WRH 100%METHANDL? YES [:j NO 99 OTHER 0.CORROSION ❑ 1 POLMNLS EWRAP ❑2 TAR OR ASPHALT n 33 WW WFIAP 4 FIBERGLASS REINFORCED PASTIL PROTECTION Ej5 CATHODIC PROTECTION E]01 NONE ff 95 UNKNOWN EJ99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U BI NONE A UNKNOWN A U 99 OTHER B.CONSTRUCTION A U i SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE L 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 A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 8 CONCRETE A LA I STEEL CLAD W/FRP A U 8 10091 METHANOL COMPATIBLE FRP A U 9 GALVANIZED SPEl��9 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR B FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION 0 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P 8 8 PRECISION TESTING 11 8 7 PRESSURE TESTING P 8 91 NONE 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 GALLON* INERT MATERIAL? [:]YES [::]NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIONATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY R FACILITY 10 8 TANK ID 8 Q� o o i 5 .5 S o00F CURRENT LOCAL AGENCY FACILITY ID R APPROVED BY NAM[ PHONE B WITH AREA COON PERMIT NUMBER PERMIT APPNOVAL DATE PERMIT EXPIRATION DATE CHECK 9 PERMIT AMOUNT BURCHAROE AMT. FEE CODE RECEIPT E �IFORMS(O-29-88) THIS FORM MUST BE ACCOMPa_A BY A FACILITY/SITE APPLICATION, FORM 'A',UNI.C.—i CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY /