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TATE 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. Z e 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION �❑^7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ IIS 6 TEMPORARY TANK CLOSURE TANK REMOVED to 1 N FACILITY/SITE NAME WHERE TANK IS INSTALLED: nor, , ^YA,.F �-�I gyp A Sr FARM TANK-YES❑ NO &Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY ir4LE O A. OWNERS TANK ID B. MANUFACTURED BY: )i k N C.YEAR INSTALLED tt N L D. TANK CAPACITY IN GALLONS: 900 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ i MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY �95 UNKNOWN WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.# C.A.S.B: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I DOUBLEWALLEO ❑ 3 SINGLE WALLED WITH EXTERIOR LINER jo�r95 UNKNOWN SYSTEM ❑2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ;ZI STEBUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGIASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER UNED F-12 ALKYD LINING ❑3 EPDXY UNING E] 4 PHENOLIC LINING LINING ❑ 5 GU55 LINING ❑ 8 UNLINED OB 95 UNKNOWN ❑ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL?, ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 4KA5 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IFAPPLICABLE A.SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLEWALLED A U 2 DOUBLEWALLED A U 3 LWEDTRENCH A U 91 NONE A UNKNOWN A U 99 OTHER A U 1 STEELARON 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 6CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A &UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR 8 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 6 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 OALLONB SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, N TO THE BEST OF MY KNO EDGE, S TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) ATE LOCAL AGENCY USE ONLY COUNTY B JURISDICTION R AGENCY k FACILITY IDB TANK ID B m = moo 3 oao CURRENT LOCAL AGENCY FACILLTYAPPROVED BY NAME I PHONE N WITH AREA CODE PERMIT NUMBER YY rr//]]L(j� PERMIT APPROVAL PATE CliP14ERMIT EXPIRATION DATE HECK PERMIT AMOUNT SURCHARGE AMT. NN(y FEE CODE RECEIPTN BY: FORM B(s-zs-ea) THIS FORM MUST BE ACCOMPANIED FACILITY/SITE APPLICATION, FORM'A',UNLE$8 A f FOR w Hu BEEN FRED DATA PROCESSING COPY—^I.