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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. _ MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑77 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE [ J YANK REMOVED D FACILITY/SITE NAME WHERE TANK IS INSTALLED: EI I 1 FARM TANK-YES[:] NO (,n I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY r O A. OWNERS TANK ID# J f G B. MANUF QCT ED BY: C. YEAR INSTALLED (�/K D TxGofpAcrTy IN GALLONS: II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),19 N T MARKED,COMPLETE ITEM D. A_ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑3, EL F-13 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT r—]4 GASAHOL E:] 5 JET FUEL 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&C.A.S.# Wig C.A.S.#: v� III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM FP44GLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEL/IRON E:]2 STAINLESS STEEL F-] 3 RBERGLASS [74 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE E]6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 IN%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZE)STEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PHENOLIC UNING LINING ❑5 GLASS UNING ❑6 UNLINED 01 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR DR ASPHALT ❑3 VIYYLWRAP ❑ 4 RBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑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 B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE AE)95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 I9 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A ID95 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 9 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 9 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS InY((v\�•Z� P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING 09 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH IVA SUBSTANCE REMAINING IN GALLONS 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# ® bb / 71016101 CURRENT LOCAL AGEjJCY FACILITY ID# APPROVED BYN E PHONE#WITH AREA CODE I a PERMIT NUMBER PERMIT APPROVAL DATE/ NERMIT EXPIRATION DATE 1 CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: \� FORM 8(6-29-3e) THIS FORM MUST BE ACCOMPANIED-BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A'WRRENT FORMA' HAS BEEN FILED