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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM meq°' x TANK TANK PERMIT APPLICATION INFORMATION ( a COMPLETE A SEPARATE FORM WITH THE FOLLOWIN FORMATION FOR EACH TANK. - Z 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYCLO ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE E:18 TANK REMOVED N / FACILITY/SITE NAME WHERE TANK IS INSTALLED: 22 S 4 G,�(j Q S'T FARM TANK-YES❑ NO A I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N A. OWNERS TANK ID# B. MANUFACTURED BY: U LrI C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 006, II. TANKCONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. i MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑4 OIL �PROOUCT ❑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) i 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 BOX A,B,C,&D A.TYPE OF ❑ I OUBLEWALLED F—] 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM LE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 iw%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING n 4 XNOUC LINING LINING ❑5 GLASS LINING ❑6 UNLINED 95 UNKNOWN ❑ 15 LINING MATERIAL COMPATIBLE WITH IDD%METHANOL? ❑YES NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR DR ASPHALT INYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMAT ON CIRCLE A IFABOVEGROUND, U IFUNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 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 U 5 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 6 CONCRETE A U 7 STEELCLADW/FRP A U S 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR 8 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 3 1 VISUALCHECK Ila P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS DP 6 PRECISION TESTING P 3 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. FORMATION 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 ❑ 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) GATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# Q1 0191 -71 1 ovv CURRENT LOCAL AGENCY F CILITY IO Y APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER 1 PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK x PERMIT AMOUNT SURCHARGE AMT. FEE CODE PxCEIPT# BY:� FORM B 16-29-88, THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM•A• HAS BEEN FILED -AIA PROCESSING COPY