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STATE OF CALIFORNIA WATER RESOURCES CONTROL IARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM ; TANK PERMIT APPLICATION INFORMATION } ° ' TANK CO PLETE A SEPARATE FORM WITH THE FOLLOWIN NFORMATION FOR EACH TANK. 1 MARK ONLY iNEW PERMIT El3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS K ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED F61 FACILITY/SITE NAME WHERE TANK IS INSTALLED: J /" FARM TANK-YES❑ NO 00 I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C.YEAR INSTALLED /9 D. TANK CAPACITY IN GALLONS: 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 ETROLEUM B. C. ❑1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT 4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 J EL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN 2 WASTE ❑7 METHANOL OTHER(DESCRIBE IN/REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.4Z2_0-3_5"' . Zr7 3 J/ HAZARDOUS SUBSTANCE STORED&C A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 100%MENANO PATIBLEFRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 FV05LIC LINING C.INTERIOR ❑5 GLASS LINING F-16 UNUNED UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VJeWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE L jar%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 2 PRESSURE A U 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 U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) U FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A STEEL CLAD W/FRP A 8 100% ETHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A 9 OTHER lei V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUALCHECK P S 2 INVENTORY RECONCILIATION P8 3VADOSE WELL P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P 8 91 NONE P 8 95 UNKNOWN P B 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 GALLONS INERT MATERIAL? ❑YES [_-] NO 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 N AGENCY# FACILITY ID# TANK ID# m OQ y aao / CURRENT LOCAL SSENCY FA ILITYJp APPROVED BY PHONE#WITH AREA CODE PERMIT NUMBER1(� (7/1 PERMIT APPROVAL DATE , , PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIEb-Vf A FACILITY/SITE APPLICATION, FORM 'A',UNLESS AtTARENT FORMA HAS BEEN FILED