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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION go COMPLETE A SEPARATE FORM WITH THE FOLLOWIN "FORMATION FOR EACH TANK. Z 10 MARK ONLY ❑ I NEW PERMIT F-13 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERM, ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: W S �1 FARM TANK-YES❑ NO N W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY a) A. OWNERS TANK ID# L)K B. MANUFACTURED BY: Ole-, DO C YEAR INSTALLED D. TANK CAPACITY IN GALLONS: l/ II. TANK , ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A_ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. G ❑ 1 UNLEADED LEADED ED DIESEL ❑ 3 CHEMICAL PRODUCT F-] 4 OIL p, DUCT ❑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) 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 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM [a.MNGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER TEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERG ASS REINFORCED PLASTIC S.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RUBBERUNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑ 5 GLASS LINING LA4-MUNED ❑95 UNKNOWN ❑IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 PDLYEW&BE WRAP ❑2 TAR OR ASPHALT ❑3 VIWLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODICPROTECTION ❑A NONEO ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMAT ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER S.CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A 1 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 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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 S 1VISUAL CHECK 8 2 INVENTORY RECONCILIATION P S 3VADO$EWELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 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 I.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID S TANK ID# CU T LOCAL AGENCY FACILITY ID# PHONE#WITH AREA CODE -- PERMIT APPROVAL DATE PERMIT EXPIMTON DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY FORM B B-29-8B) THIS FORM MUST BE ACCOMPA6._v of A FACILITY/SITE APPLICATION, FORM 'A',UNLESS AMENENT FORMA' HAS BEE.:FILED