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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. a: MARK ONLY ❑ 1'NPiVlERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM 2INTERIM PERMIT ❑4 AMENDEDPERMTT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED C)24 FACILITY/SITE NAME WHERE TANK IS INSTALLED: 0 FARMTANK-YES❑ NO Ylz I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN'SO SPECIFY IC A. OWNERS TANK ID N B. MANUFACTURED BY: G C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: D II. TANK ,PlIfTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COM ETE ITEM D. A 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. NLFADED ❑ 2 LEADED ❑ 3 DIESEL F-1 B. PRODU3 CHEMICAL PRODUCT ❑4 OIL CT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY [D 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.N C.A.S.*: /l•// All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D 1 WALLED F-13 SINGLE WALLED WITH EXTERIOR UNER E] 95 UNKNOWN A. TYPE OF 1:1 SYSTEM L&T2 SING ALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEL/IRON ❑2 STAINLESS STEEL F-13 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOLCOMPATIBLEFRP ❑ 9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD NG ❑3 EPDXY LINING ❑1 PHENOLIC LINING C. INTERIOR LINING ❑5 GLASS LINING LINED ❑95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 10D%METHANOL? [—]YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 T RASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 1 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATI N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH 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 C.MATERIAL A U 5 ALUMINUM A fi CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 5 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 ISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P RECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S %UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST2.USED(MIA R ESTIMATED QUANTITY OF 3. WAS TANK BILLED WITH A SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑NO GALLONS THIS FORM HAS BEE 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 N JURISDICTION N AGENCY N FACILITY ID N TANK ID* 0 1vo CURRENT LOCAL AGE F ILITY IOY APPROVED BY WIY ONE*WITH AREA CODE 1 PERMIT NUMBER k3a PE IT EXP71ATION DATE ``v`\1111 CHECKkPERMIT AMOUNT SURCHARGE A FEE CODE RFWEIPTN BY: - -L� i FORM B(3-7-BB) THIS FORM MUST BE ACCOMPANIED 0-%FACILITY/SITE APPLICATION, FORM 'A',UNLESS A C NT FORMA' HAS BEEN FILED <,)CESSI