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I Alt OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING#IfORMATION FOR EACH TANK. _ •, MARK ONLY ❑ 1 NEW PFJLMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYCLOSED ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT El TEMPORARY TANK CLOSURE ❑B TANK REMOVED/ y FACILITY/SITE NAME WHERE TANK IS INSTALLED: /„,�1 iJ '✓. ' Z M f',EQ/LL FARM TANK-YES❑ O ��1 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID p / 8. MANUFACTURED BY: C� C. YEAR INSTALLED / 0. TANK CAPACITY IN GALLONS: 5 / If. TANK NTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D F1 A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑i OIL 1 PRODUCT ❑< 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 6 C.A.S.N CA.S.N: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C,A D ffTYPE ❑EOOUBUWALLM ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN ❑ ❑1 SECONDARYCONTAINMENT ❑99 OTHER ❑ ❑2 STAINLESSSTEEL. ❑3 FIBERGLASS ❑ STEEICLAD W/fIBBIGLA$$REINFORCED PLASTIC❑ ❑6 POLYVINYLCHLORIDE7ALUMINUM ❑ B IW%METHMNOLCOMPATIBLEFRP ❑ ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I NUBBERUNED ❑2 ALKYDUNING ❑3 EPDXY LINING ❑/PHENOUCUNING LINING ❑5 GLASS UNING ©6 UNUNED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%MOHANOL7 ❑YES ❑NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLFNEWRAP ❑2 TAR OR ASPHALT ❑3 VIWLMIAP ❑1 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHMC PROTECTION ❑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 I SUCTION A U 2 PflESSUHE A U 3 GRAVITY A U 91 NONE A U 85 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I 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 fi CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A 72 89 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 3 1VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 6 PRECISION TEP 8 3VADOSE WELLS P S A Pp MONITOR P B SGROUNO WATER MONITORING WELLS TESTING -------P S ]PRURE TESTING P g 91 NONE P g 95 UNKNOWN P g 99 OTHEfl VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1, ESTIMATED DATE LAST USED(MONA) 2. ESTIMATED QUANTITY03.WAS TANK FILLED WITH SUBSTANCE REMAININGGIN INERT MATERIAL? GALLONS ❑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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY / COUNTY p JURISDICTION N AGENCY N FACILITY IDN TANK ID N CURRENT LOCAL AGENCY FACILITY ID N / APPROVED by NAME PHONE N WITH AREA CODE Jul r4 G PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 77 DHEDKI PERMIT AMOUNT SURCHARGE AMT. v � FEE CODE RECEIPT It Y. {OflMB(6-29-88) THIS FORM MUST BE ACCOYPANIE�o AFAULITT/SITEAPPLICATION, FORM 'A' UNLESSA DATA PROCESSING COPY ,,,,�ILRENT FORY'A' HAS BEEN FILED