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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM w TANK c TANK PERMIT APPLICATION INFORMATION .mc'o ro �" COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT CHANGE OF INFORMATION 7/lERMANENTLYQLOSEDJAYK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVE O FACILITY/SITE NAME WHERE TANK IS INSTALLED: Tlii�� l FARM TANK-YES❑ NO Q 2S Etf 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERSTANKID# I I B. MANUFACTURED BY: u 9— C. YEAR INSTALLED V� I D. TANK CAPACITY IN GALLONS: O 5 11. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. Q ., A ❑ 1 MOTOR VEHICLE FUEL 2 PEWROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT 4 OIL ❑' 1 ODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN 2 WASTE ❑ 7 METHANOL E.9�OTHFA(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF /� HAZARDOUS SUBSTANCE STORED&C.A.S.# GUASfe. U 4 r C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ !,DMBLE WALLED F--] 3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM LEWAU.ED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER cEf 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CUD W/FlBERGIASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 6 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER UNED ❑2 ALKYDUNING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑5 GLASS UNING ❑6 UNLINED EKUNNK�KNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑yB9THER D. CORROSION ❑ 1 POLVE7HLENE WRAP 2 TAA OR ASPHALT ❑3 VINYL 4 FIBERGLASS REINFORCED PLASRC PROTECTION E] 5 CATHODICPROTECTION ❑91 NONE 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 U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER ,R I 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 VV A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATEflIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL 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 S I VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 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 LGALLONS AST USED(MO/YR) 2. ESTIMATED QUANTITY OF 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# U = = I dol3 I J 6a CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE M WITH AREA CODE S PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 11/ CNECK# PERMIT AMOUNT SURCHARGE ANT. FEE CODE RECEIPT# BY: FORM a(6-29-88, THIS FOflM MUST BE ACCOMPANIED A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORMA HAS BEEN FILED DATA PROCESSING COPY