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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD -- - FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION m® COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ;A ONE IMARK TEM 1 NEW PERMIT ❑3 RENEWAL PERMIT LJ S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO SED TANK 21NTERIMPERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 6 B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: a '7/✓ / S FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IDq 1C) B. MANUFACTURED BV: V C. YEAR INSTALLED I D. TANK CAPACITY IN GALLONS: IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. W A. 1 MOTOR VEHICLE FUEL F-12 PETROLEUM B. C. ®�1 UNLEADED ❑2 LEADED ❑3 DIESEL 0 ❑3 CHEMICAL PRODUCT ❑ 4 OIL ❑1 PRODUCT u 4 GASAHOL ❑5 JET FUEL ❑ 6 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.# C.A.S.#: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,8 D A TYPE OF 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM IIIITI�-��-'L��yyyY 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER B.TANK u 1 STEEL/IRON ❑2 STAINLESSSTEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑W OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METMANOL? YES [-] NO OTHER D. CORROSION ❑ 1 POLYEFHLENE WRAP ❑2 TARORASPHALT ❑3 VINYLWRAP ❑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 Ul 1 SUCTION A U 2 PRESSURE A U 3 GRAVITYA 9 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH U UNKNOWN A U 99 OTHER A 6) STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U S ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U B 1 OD%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. [LIS 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS S 6 PRECISION TESTING P S I PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH 7� SUBSTANCE REMAINING INGALLONS INERT MATERIAL? E]YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPL ANTS NAME(PRIN DASIGNATUR DATE j 7 / g' LOCAL AGE4CN0 USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# K` ] = lo I a o Oov3 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY IIA PHONE#WITH AREA CODE " �z Ig - PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE \\\1r`I CHECKp PEflMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: V FORM B(3-7-B8) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE MPLICATION, FORM 'A',UNLM A CURRENT FORMA HAS BEEN FILED -`ATA PROCESSING COPY T+�