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S I ATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION ,o COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ ' NEW PERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIMPERMIT ❑4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE �B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: O0 LC, FARM TANK-YES❑ NO lie Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 A. OWNERS TANKID# -2 B. MANUFACTURED BY: C. YEAR INSTALLED 41A D. TANK CAPACITY IN GALLONS: IWO 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. Hca OS A Ef'1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑.el_EADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑q OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ BO EMPTY ❑ 95 UNKNOWN 1 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAMEOF HAZARDOUS SUBSTANCE STORED a C.A.S.# C.A.S. All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A TYPE OF Lal DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 UNING ❑3 EPDXY LINING ❑4 PHENOUC UNING LINING ❑5 GLASS UNING 6 UNUM ❑ 95 UNKNOWN ❑IS UNING MATERIALCOMPATIBLE MM 100%METHANOL? ❑YES ❑NO ❑990 D. CORROSION ❑ 1 POLYED0.ETA WRAP ❑2TAR OR ASPHALT ❑3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 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 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U- DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD WIFRP A 1 DD%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 P 8 2 INVENTORY RECONCILIATION 0 8 3 VADOSE WEP 4 ELECTRONIC MONITOR P 8 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE LLSs 95 UNKNOWN P 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1, ESTIMATED DATE LAST U ED(MO/YR) 2, ESTIMATED QUANTITY OF3.WAS TANK F ED WITH OALLONB SUBSTANCE REMAINING IN INERT A L? ❑YES [:]NO THIS FORM AS AEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO HE BEST OF MY KNOWLEDG IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY B�OUNT # JURISDICTION# AGENCY# FACILITY ID# TANK ID# L�1�J o G1 010 IL I CURRENT LOCAL AGENCY FACILITY IDN APP D BY FjANIi PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL PERMIT EXPIRATION DATE CXECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: FORM B(3-7-88) THIS FORM MUST BE ACCOBY A FACILITY/SITE APPLICATION, FORM `A',UNLE FORMA' NAS BEEN FILED DATA PROCESSING COPY