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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION m �' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. G MARK ONLY ❑ i NEWPERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TAN91,M) 10 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED Of FACILITY/SITE NAME WHERE TANK IS INSTALLED: 9Cj �' /� G`FARM TANK•VES NO / I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY N A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED �,�� D. TANK CAPACITY IN GALLONS: Q 0 II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. 3 DIESEL DED A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM C. ❑ 1 UNLEADED LEA ❑ F-1 B.3 CHEMICAL PRODUCT ❑4 OIL 6<PRODUCT ❑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.8 C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A TYPE OF ❑I DOUBLE WALLED ❑3 SINGLE WALLED WRH EXTERIOR UNER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRDN ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALU ❑81 W%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑10 GALVANIZEDSIEEL UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBEfl LINED —]2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHE LINING LINING ❑5 GLASSUNING ❑6 UNUNED UNKNOWN ❑ISUNINGMATUMLCOMPATIBLEWRHIDD%MEmNOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION F7 I POLYETHUENEWRAP F-1 2 PROTECTION F]5 CATHODIC PROTECTION [—]91TAR OR NONE ASPHALT [:]3 V EiAr-KNOWN 99FIBERGLASSSREINFORCED PLASTIC HER IV. PIPING INFORMATION 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 91 NONE A 95 LINKNO 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 1@5 UNKNO A U 99 OTHER A U 1STEEL/IRON A U 25TAINLE85 STEEL A U 3POLYVINYL CHLORIDE(PVC) A U 4FIBERGLASS PIPE A U 91 NONE CY MATERIAL A U 5 ALUMINUM A U 6 rnN ETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U95 UNK OW 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 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P<_95 UNKN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OFOALLONB 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN 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 S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION N AGENCY 8 FACILITY ID E TANK ID 8 3 F71 1 1 aI a- y 010101 /1 curff LOCAL AGENCY FACILITY ID• APPROVED BY NAME PHONE•WITH AREA CODE PERP _ MR APPROVAL DATE PERMIT EXPIRATION DATE CHECK• PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT k BY: FORM B(S-29-88) THIS FORM MUST BE ACCOMPANIEO'dY A FACILRY/SRE APPLICATION, FORM'A',UNLESS A CURRENT FORMA' HAS BEEN FILECD✓S DATA PROCESSING COPY