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STATE OF CALIFORNI WATER RESOURCES CONTRC IOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION m ' TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z 10 MARK ONLY 1 NEW PERMIT F-13 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED T K ONE ITEM 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑e TANK REMOVED / FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1 0 3 FARM TANK-VES❑ NO (A,) I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-50 SPECIFY N A. OWNERSTANKIDR 7 B. MANUFACTURED BY: C. YEAR INSTALLED G D. TANK CAPACITY IN GALLONS: D II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. 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 E] 6 AVIATION GAS ❑5 HAZARDOUS [—] 80 EMPTY E]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 8 C.A.S.B C.A.S.R: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF DOUBLEWALLED ❑ 3 GLE WALLED WITH D ERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑!SEC DARY CONTAINMENT ❑99 OTHER I STEEL/IRON ❑2 STAIN L ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGUSS REINFORCED PLASTIC S. TANK 5 CONCRETE 6 POLYWNYLC RIDE ❑7 ALUMINUM B 1DD%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED ❑95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYDUNING ❑3 EPDXY LINING ❑4 PHENOUC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑6 UNLINED E]95 UNKNOWN ❑ISUNING MATERIALCOMPATIBLEWITH 100%METHANOL? ❑,VES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHIENEWRAP ❑2 TAR OR ASPHALT ❑3 \NYLWMP ❑ 4 RBERGUSS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑97 NONE ❑95 UN((NONN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A FABOVEGROUND, U IFUNDER OUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 ZTAVITY 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 LIN05q TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYV)VfLCHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U7 STEELC 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER W/FRP A U 8 V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. L� P S 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS er/6 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS ``��II P 8 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE 8 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 /7' /I GALLONS SUBSTANCE REMAINING IN 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 B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION a AGENCY P FACILITY ID R TANK ID M U SSS 161010171 CURRENT LOCAL AGENCY FACILITY IDA APPROV D BY NAME X^ rXE PHONE K WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE I PSI EXPIRATION DATE CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT M BY: W/ FORM B(6 29 88) THIS FORM MUST BE ACCOMPANM BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS URRENT FORMA HAS BEEN FILED DATA PROCESSING COPY