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STATE OF CALIFORNIA WATER RESOURCES CONTROL r' ARD FORM 'B': UNDERGROUND STORAGE TANK PROGWAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. o MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATIONPERMANENTLY CLOSED TANK 1 ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E]6 TEMPORARY TANK CLOSURE E8 TANK REMOVED 0 FACILITY/SITE NAME WHERE TANK IS INSTALLED: QQ AFf !/d FARM TANK-YES❑ NO N 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# U. �, CD B. MANUFACTURED BY: G�, Q O. YEAR INSTALLEDI/ D. TANK CAPACITY IN GALLONS: 5 (lri aw IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 P ROLEUM 8. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT 4 OIL 1 PRODUCT ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS ❑ 5 HAZARDOUS ❑60 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.q �O w4::�T— o 7 L. C.A.S.q; III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A B,C,A D A. TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WTTH EXTEROR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC 8.TANK F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 MINUM ❑81DAMETHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL LaT95 UNKNOWN E] 99 OTHER C. INTERIOR ❑ 1 RUBBERUNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 NOUCUNING LINING ❑ 5 GLASS UNING ❑6 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2TAR OR ASPHALT ❑ 3 LWRAP ❑4 RBERGLSS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION 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 i SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A ig 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 A745 95 UNKNOWN A U 99 OTHER A U1 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 STEEL CLAD W/FRP A U S 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL Ad 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 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 DOSS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONEVAE WELLP 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED IMO/YR) 2. ESTIMATED QUANTITY OF T WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES SUBSTANCE ❑NO i 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# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FA IIITY IDN APPROVED BY NAME PHONE k WITH AREA CODE PERMIT NUMBERPERMIT APPROVAL DATE PERMIT EXPIRATION DATE CNECKN PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT BY: 3 6 FORM B(6-29-M) THIS FORM MUST BE ACCOMPANIEAY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A M--..RENTMRENT FORA' HAS BEEN FILED 1-�