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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION fro COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. �. 1 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT L3"5'CHANGE OF INFORMATION ❑7 PERMANENTLYCL 1 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 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# D B. MANUFACTURED BY: IoY C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: D II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. _ C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL F-]3 CHEMICAL PRODUCT ❑ PRO 4 OIL 1 DUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6VIAT'ON GAS ❑5 HAZARDOUS ❑80 EMPTY E]95 UNKNOWN ❑ 2 WASTE 117 METHANOL E]99 OTHER(DESCRIBI IT ,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF p HAZARDOUS SUBSTANCE STORED&CA.S.# I (7 D 6731-3 S6 L t 7 f l.tc eld C.A.S." 2 XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF EP"'DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑ 2 SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER I r 1 STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CIAO W/FIBERGLSS REINFORCEDPLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 ON METHANOL COMPATIBLEFRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑�2 ALKYD UNING F-13 EPDXY LINING ❑4 PHENOLIC UNI NO LINING ❑5 GLASS LINING o°UNLINED ❑95 UNKNOWN i ❑ IS DINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR 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 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 �Up 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A 1U 18 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V ^i7-LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS 4 ELECTRONIC MONITOR P S S GROUNDWATER MONITORING WELLS P S S' PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMAUED DATE LAST USED(MO/VR) 2. ESTIMATEP QUANTITY OF 1 3.WAS JANK FILLED WITH SUBpfF REMAINING IN E TERIAL? ❑YES F] NO GALLONS THIS ORM HAS BEEN COMPLETED UNDER PENALTY O PERJURY,AND TO THE BEST OF MY KNOWL GE, IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY / O/ e2 hj' y COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 6 11 IY14-R 10 10 10 CURRENT LOCAL AGENCY FACILITY 10# APPR VE B AME PHONE#WITH AREA CODE a -o !�v �� PERMIT NUMBER PERMITAPPROVALDATE PERMIT PIRA ON ATE CHECKM PER MIT AMOUNT SURCHARGE AMT. FEE CODE RECFIPT# BY: _~`\JCIJI FORM B(3-7-86) THIS FORM MUST BE ACCOMPANIED BTA FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CUR INT FORMA' HAS BEEN FILED DATA PROCESSING COPY _ J