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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM `N TANK TANK PERMIT APPLICATION INFORMATION COMPL 7E A SEPARATE FORM WITH THE FOLLOWING IN OMATION FOR EACH TANK. Z 10 MARK ONLY NEW PERMIT ❑3 RENEWALPERMIT ANGE Of INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM F72 INTERIM PERMIT F—] 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE E]8 TANK REMOVED Q', N FACILITY/SITE NAME WHERE TANK IS INSTALLED: �,vU �. FARM TANK-YES❑ NO .� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY IV A. OWNERS TANK ID# B MANUFACTURED BY: v G YEAR INSTALLED D. TANK CAPACITY IN GALLONS: , II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COM LETE ITEM D. A. 1 MOTORVEHICLE FUEL ❑ 2 PETROLEUMC. 1 UNLEADED ❑ 2 LEADED E] 3 DIESEL F-13 CHEMICAL PRODUCT ❑4 OIL B. 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 OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXA,B,C,BD A.TYPE OF ❑ I DOL EWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SING ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEUIRON ❑2 STAINLESS STEEL F7 FIBERGLASS ❑ 4STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP MATERAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER F—] 1 RUBBER LINED E] 2 ALKYD LINING ❑3 EPDXY LINING ❑4 PH CLINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑6 UNUNED UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH IOD%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLBNE WRAP ❑ 2 TAR OR ASPHALT 3 VI P ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 9/ NONE U 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 6 CONCRETE A U 7 STEELCLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DEFECTION SYSTEM MUST BE CIRCLED. 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS "''UUU11L P 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USFp O/VR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? [-]YES ❑ NO THIS FORM HAS a6EN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# = U I cD I <�)I c-- z CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAM PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE P RMI EIIPIRAT10711ATE CHECKN PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT k BY: FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIE"u'dY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS REIT FORMA' HAS BEEN FILED DATA PROCESSING COPY