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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 1 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO ❑ W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N O A. OWNERS TANK IDN B. MANUFACTURED BY: C. YEAR INSTALLED (�(� D. TANK CAPACITY IN GALLONS: I�y Imp IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A ❑[glfMOTOR VEHICLE 3 CHEMICAL PRODUCTL ❑4 OIL ROLEUM B 1 PRODUCT C ❑ 1 UNLEADED ❑ 2 LEADED DIESEL ❑ /GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY [-] 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) I, D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.N C.A.S.M III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EATEROR LINER 95 UNKNOWN SYSTEM ff�SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER EkfauIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS 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 ❑ 1 RUBBEFUNED ❑ 2 AL DLINING F-13 EPDXYLINING ❑ 4 PHENOLICUNING LINING ❑5 GLASS UNING EjJ41NUNED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IDD%METHANOL? ❑YES E]NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP [-]2T M RASPHALT 3 VIWLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION L InLlf NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPEU 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A n> SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER ASTEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER II V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM NfwR BE CIRCLED. / P S IVISUAL CHECK 0's 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P B 4 ELECTRONIC MONITOR P 8 5 GROUND WATW MONITORING WELLS ✓h P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MONR) 2. ESTIMATED QUANTITY OF GALLONS 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? [:]YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER'PENALTYOF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AN CORRECT. APPLICANT'S NAME(PRINTEO B SIGNATURE) DATE - 1 LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY IDN TANK ID N 3IS] 106M5 000 CURRENT IOOAL AGENCY FACILITY IDN APPROVED BY NT .yp PHONE N WITH AREA CODE (1/�`J K I I fr_ PERMIT NUMBER PERMITAPPROVAL DATE ERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE JIECEIPT N BY: FORM B(6-29-BB) THIS FORM MUST BEACCO;jiIBD FACILITYISRE APPLICATION, FORM 'A',UN A FORMA' HAS BEEN FILED DATA PROCESSING COPY