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STATE OF CALIFORNU WATER RESOURCESCONTRO' ')ARD FORM `B': UNDERGROUND STORAGE TANK PROCX'r�AM (az TANK TANK PERMIT APPLICATION INFORMATIONCOMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 111 €O MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY K ONE ITEM F-1 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO �. 0 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: ok C. YEAR INSTALLED44t D. TANK CAPACITY IN GALLONS' QQQ 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A OTOR VEHICLE FUEL ❑2 PETROLEUM8. C. ❑ 1 UNLEADED E]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 OF6W1�0/L/'. /pip HAZARDOUS SUBSTANCE STORED& G.A.S.#: I11. TANK CONSTRUCTION MARK ONE ITEM O LY IN BOX A,B,C,&D A. TYPE OF ❑ UBLEWALLED F-13 SINGLE WALLED WITH E%TERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER '.. ❑ STEEL/IRON ❑ 25TAINLES66TEEL F-13FIBERGLASS F74STEEL CUDWIFIBERGLASS REINFORCED PLASTICB.TANK 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER LINED ❑2 ALKYD LINING [:j3 EPDXY LINING ❑4 E14OUC LINING LINING ❑5 GLASSUNING ❑fi UNLINED 95 KNOWN ❑ IS UNINGMATERIAL COMPATIBLEWITH 100%METHANOL? [—]YES NO 99 OTHER D. CORROSION ❑1 POLYETHLENE WRAP ❑2 TAR OR ASPHALTNYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION [_]5 CATHODIC PROTECTION E]91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, 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 N5 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 9/ NONE A 45 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUMA B CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A UNKNOWN A U 99 OTHER r V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. n I S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P B 3 VADOSE WELLS P 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS '11TH_] P 5 6 PRECISION TESTING P S ] PRESSURE TESTING P S 91 NONE S 5 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATEDOUANTITY OF 3.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 APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID N TANK ID# ® = = 1Cq 10 / / Lq 1(9O CURRENT LOCAL AGENCY FACILITY ID#i6 a APPROVED BY NAME PHONE#WITH AREA CODE r{ PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK X PERMIT AMOUNT I SURCHARGE AMT. FEE CODE RECEIPT R BY:V- lJ EORV 616 29-aS THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS CURRENT FORMA' HAS BEEN FILED /YJJ PROCESSING COPY