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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. Z 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT L_j 5 CHANGE OF INFORMATION ❑�7 PERMANENTLYCLO AN ONE ITEM 1:12 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE Iv TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: AJ AAw it ff FARM TANK-YES NO 4b- W 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# D B. MANUFACTURED BY: rK C. YEAR INSTALLED 7 L 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. MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL �RODUCT ❑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 8 CA.: IZA C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BORA,B,C,SD A. TYPE OF �IE��1^DOUBLE WALLED F-] 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM u`SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CIAO W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM F-18 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR I RUBBER LINED ❑2 AM LINING ❑3 EPDXYLINING 714 PHENOLIC LINING LINING ❑5 GLASS LINING 6 UNLINED ❑95 UNKNOWN/�� ❑ IS LINING MATERIAL COMPATIBLE WITH 100%MENANOL7 ❑YES [-] NO OTHER A D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 YINYL WRAP ❑4 FIBERGLAS$REINFORCEDPUSTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 0 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMAT N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A B 99 OTHER B. CONSTRUCTION A W 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 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL CLAD W/FRP A U S 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A 95 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 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS ' f P S 6 PRECISION TESTING S 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER f VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAPT USED(MO/YR) 2. ESTIMATED UANTITY OF 3.WAS TANK RL D WITH SUBST 64MAINING IN INERT T A ❑YES ❑ NO ✓y /l OALLONB THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# C c' -E TANK ID# oo 1 10101011 CURREtIT LOCAL AGENCY FACILITY ID N APPROV BY NAM PHONE N WITH AREA CODE 6 14/"^/ ;v PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATIO DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT k BY: U J CORM R(5-29-m) THIS FORM MUST BE ACCOMPANB:DBY A FACILITY/SITE APPLICATION, FORM 'A',UNLES. RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY