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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM .,:.. ^F. TANK TANK PERMIT APPLICATION INFORMATION '" �o- n COMPLETE A SEPARATE FORM WITH THE FOLLOWING I RMATION FOR EACH TANK. �+ MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE /�. FACILITY/SITE NAME WHERE TANK IS INSTALLE /0 �, FARM TANK-YES❑ NO z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS B. MANUFACTURED BY: 6 r C YEAR INSTALLED /ZC� D. TANK CAPACITY IN GALLONS GN II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. N A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. �� C. UNLEADED ❑ 2 LEADED ❑3 DIE �/ ❑3 CHEMICAL PRODUCT ❑ 4 OIL fi0DUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS / ❑5 HAZARDOUS ❑ BO EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF ,2 HAZARDOUS SUBSTANCE STORED&C.A.S.N C.A.S.K: L3 .111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF/ -,)' El DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER Et-95 UNKNOWN /7 ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑2 STNNLESSSTEEL F-13 FIBERGLASS -]4 STEEL CIADW/FlBERGVSS REINFORCED RUSTIC B.TANK I ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEELNKNOWN ❑99 OTHER C. INTERIO ❑ 1 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑4 PHENOLIC UNI NG NUNED 95 UNKNOWN LINING �( ❑❑� LINING COMPATIB�THL100%METHANOLF0 YES $ff'NO ❑99 OTHER 0.CORROSI ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 V�IWLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTIO E]5 CATHODIC PROTECTION ❑91 NONE �9SUNKNOWN ❑99 OTHER IV. PIPING INFO ATION 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 U 99 OTHER U B.CONSTRUCTIO A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 5 UNKNOWN A U 99 OTHER A U1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE 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 A Irip95 UNKNOWN A U 99 OTHER OV. ETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VAOOSE WELLS P 9 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS �n P S 6 PRECISION TESTING P S 7 PRESSURE TESTING all 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1 TIMATED DATE LAST USED IMO/YR) 2. ESTIMATED QUANTITY OF DALLONB 3.WAS TANK FILLED WITH y./. SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES F]NO �Y N THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) GATE LO AL AGENCY USE ONLY �!! COUNTY A JURISDICTION N AGENCY N Ifo FACILITY IDN 27 TANK ID k 0 CSG CU NT LOCAL AGEN FACILITY LD• D BY NAME PHONE N WITH AREA CODE 0f2R/ �i /Y PERMIT NUMBER IT APPROVAL TEV PERMIt EJPI TION DATE CHECK M PERMIT AMOUNT SURCKARGE AMT. FEE CODE RECEIPT X BY: F RMB(3-7-66) THIS FORM MUST BE ACCOMPANItnY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A'CORRENT FORMA HAS BEEN FILED DATA PY:OCLSS;NG COPY