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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 F-1 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLYCL ONE ITEM ❑ 21NTERIMPERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: �' -p_(�.�YW`� FARM TANK-YES NO Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY J IQ �'- A. OWNERS TANK ID# 05- 0. MANUFACTURED BY: Irn C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 4 ,406 u 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. [kj MOTOR VEHICLE FUEL F-] 2 PETROLEUM B. C. [!�r-1 UNLEADED 0 2 LEADED D 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL 9�i PRODUCT ❑ 4 GASAHOL 0 5 JET FUEL 0 6 AVIATION GAS 5 HAZARDOUS 80 EMPTY D 95 UNKNOWN 2 WASTE Ej 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CAS.# PJA C.A.S.#: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,e D A TYPE OF IDOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR UNER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER STEEL/IRON 2 STAINLESS STEEL ❑3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B'TLIA�TERNLL F-] 5 CONCRETE 6 POLYVINYLCHLORIDE F-17 ALUMINUM E] 810016 METHANOL COMPATIBLE FSP 9 BRONZE 10 GALVANIZED STEEL [—]95 UNKNOWN E]99 OTHER 1 RUBBERUNED 2ALKYO LINING �3EPDXY LINING ��4 PHENOLIC UNING C.`INING NTERIOR ❑5 GLASS UNING 16`UNLINED ❑95 UNKNOWN IS UNING MATERIAL COMPATIBLE NTH 100%METNANOL? YES [:]NO F]99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TARORASPHALT 3 VINYL WRAP4 FIBERGLASS REINFORCED PLASTIC PROTECTION E]5 CATHODIC PROTECTION Ej 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 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 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 A4 FIBERGLASS PIPE C.MATERIAL A U 5ALUMINUM A U 6CONCRETE A U ]STEEL CLAD W/FRP A V8100%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 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS(P)S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 8 6 PRECISION TESTING P 8 7 PRESSURETESTING P 8 91 NONE 8 95 UNKNOWN P 8 99 OTHER W. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED ATE LAST USED(MO/YR) 2. ESTIMATED QU NTITY OF 3.WAST NK FILLED WITH SUBSTANCE REIN IN GALLONS INE ERIAL? YES 0 NO THIS FO4M HAS BEEN COMPLETED UNDER PENALTY OFIPE14JURY,AND TO THE BEST OF MY KNOWLE GE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY ) 0100o COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# G 10 11 111 10 1 D 10 1 S T LOCAL AGENCY FACILITY ID# AOV B AME PHONE#WITH AREA CODE CURREN • 1 PERMITNUMBER PERMIT APP ROYAL DATE PERMIT E%PIRA 10 DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE REC�PT# BY: FORM B(3-7-18) THIS FORM MUST BE ACCOMPANIED TA FACILITY7STfE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY `-�