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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 FOLLOWIN INFORMATION FOR EACH TANK. __�tl L Z MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT %CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDTANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED f S� FACILITY/SITE NAME WHERE TANK IS INSTALLED: F,7Q3 (U (Q1- FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID R :�— B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL W 2 P OLEUM B. - C. ❑ 1 UNLEADED [j2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT OIL PRODUCT ❑4 GASAHOL ❑ 5 JET FU ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY F]95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL THER(DEISCHIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME, n OFT W� HAZARDOUS SUBSTANCE STORED&C.A.S.)17 fKA-Ma � 1 S !;sIQr A.S.k: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,&D A.TYPE OF ❑ 1 DO WALLED E:]3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN ' SYSTEM SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER EUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ MATERIAL 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑S 109%METHANOL COMPATIBLE RAP ❑ 9 BRONZE ❑ 10 GALVANIZEDMEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR 1 RUBBER UNED E]2 AL94INING F-13 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING E4<6MLINED ❑ 95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%MEMANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHLFNEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION F91TINONE ❑95 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 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 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 U 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"'065 UNKNOWN A U 7 STEELCLADW/FRP A U B 100%METHANOL COMPATIBLE FRP L:5 A U 9 GALVANIZED STEEL A 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 CHECK 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 ]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(M YR) 2. ESTIMATED QUANTITY OF GALLONS 3.WAS TANK FILL7` ED WITH ,A/)/A SUBSTANCE REMAINING IN INERT MATERIAL? [—]YES ❑ NO THIS FORM HAS BEE COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION# AGENCY# FACILITY IDS TANK ID 8 m lolo f U U 10 / CURRENT LOCALAGENCY FACILITY ID APPROVEDBYNA E PHONE N WITH AREA CODE U til I•j�D 388' PERMIT NUMBER PERMIT APPROVAL DATE PRM EXPIRATION CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT• BY: \Y1VIII FORMB(6-29-BB) THIS FORM MUST BE ACCOMPANIEUTTA FACILITY/SITE APPLICATION, FORM`NUNLESSA FORMA' HASBEENRLED DATA PROCESSING COPY