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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': � UNDERGROUND STORAGE TANK PROGRAM .., *` TANK C/ TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEWPERMIT ❑3 RENEWALPERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY PLO •u' K ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVq 19 y FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3 {'1_` 's-r u- -0 FARM TANK-YES❑ NO U�'l1 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY11 •O A. OWNERS TANK ID R I D. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS' H. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D CJl A_ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ I UNLEADED LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL I PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.M CAS.9: Ill. TANK CONSTRUCTJON MARK ONE ITEM ONLY IN BOX A,B,C,a D A TYPE OF 1 W ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2?,hlWfWALUED 4 SECONDARY CONTAINMENT [::]W OTHER .TANK i STEELARON ❑2 STAIMfM STEEL ❑3 FIBERGUSS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED RASTIC B MATERIAL ❑5 COMTETE ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ i RUBBERUNED ❑2 AL1f1DUNING ❑ 3 EPDXY LINING ❑/PHE NTNG LINING ❑5 GLASSUNING ❑6 UNUNED UNKNOWN ❑IS UMNG MATERIAL COMPATIBLE WITH 100%METHANOL? E]YES E]No 990THER D.CORROSION ❑ I POLYETHUNE WRAP ❑2 TAR OR ASPHALT ❑3 p 4 FIBERGLASS REINFOIK,TU PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNGWN ❑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 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 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 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 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 E]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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N I�GENCY# FACILITY ID f TANK ID E I D o C> 010 ID CURRENT LOCAL A07Y FACI$LITY ID 1 APPROVED BY NAME PHONE N WITH AREA CODE I�Oh � PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK• PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT/ ar: 2 FORM B IS-29-8SX THIS FORM MUST BE ACCOMPANIcO BY A FACILITY/SITE APPLICATION, FORM 'Am,UNLESS ATURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY