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STATE OF CALIFORNIf WATER RESOURCES CONTRO"DARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM ' TANKTANK PERMIT APPLICATION INFORMATIONo,;tl G COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO K ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: /EL (� 57(CN FARM TANK-YES❑ NO - 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY f �7'0'? A. OWNERS TANK ID# B. MANUFACTURED BY: B - 4k--6 E / C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: �Q CJ II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),ISNOT MARKED,COMPLETE ITEM D. LEA A. 1 MOTORVEHICLEFUEL F-] 2 PETROLEUM Fk�lPRCIDUCT C, ❑ 1 UNLEADED 2 DED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWNSTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.N C.A.S.#: .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.A D A TYPE OF ❑ UBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ i STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 33 FIBERGLASS ❑4 BTEEL CLAD W/FIBERGLASS REINFORCED PLASTIC F-1E]B.TANK 5 CDNCPETE 6 POLYVINYLCHLORIDE n?6MINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL �/( ❑9 BRONZE ❑10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNED 2 ALKYD LINING ❑3 EPDXY LINING '''n''' 4 ENOUGUNING C. INTERIOR �G/ LINING ❑5 GLASS LINING ❑6 UNLINED �{ UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 99 OTHER D. CORROSION ❑ I POLYETHENE WRAP ❑2 TARORASPHALTn 3yMPYL WRAP F-14 FIBERGLASS REINFORCED PLASM PROTECTION [:]5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY99 OTHER S. CONSTRUCTION A 1 SINGLE A WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH 95 UNKNOWN A U 99 OTHER A U 1 STEELIIRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEEL CI-ADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 5 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. I/ S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS j h� 8 6 PRECISION TESTING P 8 7 PRESSURETESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER { VV VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? E]YES E]NO I+ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# LIE 06 1 A U 8 OOOZ MT L AGENCY FACILITY IDN APPROVED BY NAME PHONE#WITH AREA CODE PERMIT UMBER PERMIT APPROVAL DATE PERMIT E%PIRATION DATE S CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTN BY: W FORM 8(3 7-88) THIS FORM MUST BE ACCOMPANILU BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RRENT FORMA' HAS BEEN FILED L -lJ