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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM ml� TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - 10 MARK ONLY ❑ 1 NEWPERMIT F-] 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 RMANENTLY CLOSED TAN ONE ITEM ❑ 2 INTERIM PERMIT F-] 4 AMENDEDPERMIT [:]6 TEMPORARY TANK CLOSURE 8 TANKREMOVED D FACILITY/SITE NAME WHERE TANK IS INSTALLED: gs , ' �' FARM TANK-YES❑ NO IV I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY O clf CC A. OWNERS TANK ID# B. MANUFACTURED BY: (,L A' C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Q II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. 'TMOTOR VEHICLE FUF-1 2 3 DIESEL A ❑3 CHEMICAL PRODUCT ❑/OP6LfROLEUM B PRODUCT C ❑4 GASAHOL ❑ 5 JET LEADED ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,6 D A TYPE OF ❑ I DOUBLE WALLED ❑ 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 ❑5 CONCRETE ❑8 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER UNED ❑2 AL ❑3 EPDXY UNING ❑4 PHENOLIC UNING LINING ❑5 GLASS UNING NUNED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH T00%METHANOL9 ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHUNE WRAP ❑2 TA RASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A fUjI SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNEOTRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERUL A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 180%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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 8 1 VISUAL CHECK 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS 8 P PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES E] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANPS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 1010 1 / = I oAo I / CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME YR PHONE#WITH AREA CODE PERMIT N BER PERMIT APPROVAL DA PERMIT EXPIRATION DATE CHECKN PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTN BY: FORM B(5-29-B3) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA HAS BEEN FILED DATA PROCESSING COPY