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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM R .,. TANK TANK PERMIT APPLICATION INFORMATION m COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 71 NEW PERMIT 3RENEWAL PERMIT❑ ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK (O ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED (17 N FACILITY/SITE NAME WHERE TANK IS INSTALLED: 4 ccmKIg FARM TANK- ES,❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I„a A. OWNERS TANK IDR B. MANUFACTURED BY: N C. YEAR INSTALLED (L/ D. TANK CAPACITY IN GALLONS: O II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. kgl_MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL H PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS L]5 HAZARDOUS ❑80 M El 95 UNKNOWN. ❑ 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,EN NAME OF HAZARDOUS SUBSTANCE STORED C.A.S.R C.A.S. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER M STEELARON �� ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.MATERIAL F-15 CONCRETE ❑8 POLYVINYLCHLORIDE ❑7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER C. INTERIOR ❑ 1 RUBBERUNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS UNING bir6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO .1�2/99 OTHER [AK D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAO OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERWSS REINFORCED PLASTID: PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE f_ 9 UNKNOW',/'21❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUNDO UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A 91 NONE AU 5 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 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 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM ACONCRETE A U 7STEEL CLAD W/FRP A U 610096 METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A 25 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 1 VISUAL CHECK 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING 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 GALLONSINERT MATERIAL? ❑YE$ ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE NO CORRECT. APPLICANT'S NAME(PRINTED A,SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY R FACILITY ID R TANK ID R 101 0o2_ I 1 / 2- 10 1010 11 CURRENT LOCAL AGENCY FAf7g R APPROVED BY NAME PHONE N WIT"AREA CODE PER IT NUMBER PERMITNPPNO L DATE PERMIT EXPIRATION DATE CCC CHECK M PERMIT AMOUNT i'111URCHARGE AMT. FEE CODE RECEIPT N BY: \ FORM a(6-29-w) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNMSACUkRENT FORMA' HAS BEEN FILED \d\ v_._.._"TA P60G9fi¢IMG.=DY.