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STATE OF CALIFORNI.' WATER RESOURCES CONTROI `)ARD FORM 'B': UNDERGROUND STORAGE TANK PROGii!AM TANK TANK PERMIT APPLICATION INFORMATION "eb COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - 1NEW PERMIT 3RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK IC MARK ONLY ❑ ❑ ❑ ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED / FACILITY/SITE NAME WHERE TANK IS INSTALLED: 03,z S E'Yoofwok, 5il 5*" FARM TANK-YES❑ NO ❑ 00 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY _ � N A. OWNERS TANK ID X - R. MANUFACTURED BY: C. YEAR INSTALLED _ D. TANK CAPACITY IN GALLONS: Q II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED IH3 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 OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.X C.A.S.W III. TANK CONSTR CTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF FM 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL 7 3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑810M METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑2 AM LINING ❑ 3 EPDXY LINING U4 PHENOLIC LINING LINING ❑5 GLASSUNING ❑6 UNLINED 0 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IOD%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYEFHLE14E WRAP ❑2 TAR DR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODICPROTECTION ❑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 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 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 S7EELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL 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. ��1/1^� P S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P B 3 VADOSE WE S ■ S ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 1 P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE S 95 UNKNOWN P S 99 OTHER 1� VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF3.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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION k AGENCY R FACILITY ID N TANK ID B EM = = 0 I 1 13 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE WL lf'13d LCHECK# ER PERMITAPPPOVAL DATE PERMIT EXPIRATION DATE PERMIT AMOUNT IQURCHARGE AMT. FEE CODE - -1EIPTN BY: 'L ` FORM B S-29-BBI THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY