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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM ; TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMI7 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDEDPERMI7 ❑6 TEMPORARY TANK CLOSURE E:18 TANK REMOVED l C FACILITY/SITE NAME WHERE TANK IS INSTALLED: O FARM TANK-YES❑ NO T I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK IDN L \ ei/JI B. MANUFACTURED BY: 64, C. YEAR INSTALLED r v Ar D. TANK CAPACITY IN GALLONS: o O 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. C4 4O�P?� A. [011 MOTOR VEHICLE FUEL F-] 2 PETROLEUM B C. ❑ I UNLEADED al�i LEADED ❑3 DIESEL 01 ' ❑3 CHEMICAL PRODUCT ❑ 4 OIL KIPRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS Oo ❑ 5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 0 ER(DESCRIBE IN ITE ,BELOW) D. IF NOT MOTOR VEHI(jLE,FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.# CAS All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.8 D I A TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER /r� ❑ 1 STEEL/IRON ❑2 STAINLESSSTEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORS?fLASTIC B.TANK 6INYL CHLORIDE 7AL MINUM 81M%METHANOL COMPATIBLE FRP MATERIAL O B , �10 GALVANIZED STEEL UNIKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXYLINING ❑4 PHENOLICUNING LINING ❑5 GLASS LINING ❑6 UNLINED DIKUNKNOWN ❑ISUNING MATERIAL COMPATIBLE WITH IDD%METHANOL? ❑YES ❑ NO ❑ 9R OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT D VINYL WRAP F-14 FIBERGLASS REINFORCED PLASTIC PROTECTION [—]5 CATHODIC PROTECTION ❑ 91 NONE W5 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 99 OTHER . Lam(, /l\ yl O LO B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 5 UNKNOWgV` A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIUFI-ASS PIPE BOW C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 1METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AO95 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 CHECKS 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P'9' 6 PRECISION TESTING S 7 PRESSURE TESTING P 8 91 NONE P B 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE t.(�ESTIMATED DATE T.USED(MQIYF) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH /] GALLONS SUBSTANCE REMAINING IN 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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# ual I OOk 1 1010101 CURRENTLOCA AGENCY FACILI 10# APPROVED BY NAME PHONE#WITH AREA CODE O PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK k PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: \\v1T1J'I FORM B(3-7-m) THIS FORM MUST BE ACCOMPANI%. A FACILITY/SITE APPLICATION, FORM 'A',UNLESS AttORENT FORMA' HAS BEEN FILED ul y