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STATE OF CALIFORNIA WATER RESOURCES CONTROL .R?ARD FORM 'B': UNDEkROUND STORAGE TANK PROG�AM TANK TANK PERMIT APPLICATION INFORMATION yam. r,,NTREmRpIRMST� PARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 3 RENEWAL PERMIT IL�_Ly'C/" CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL NK ONE ITEM ❑ 4 AMENDED PERMIT u 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1p (,,V FARM TANK-YES❑"NO 7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS (IDN -L B. MANUFACTURED BY: _ C. YEAR INSTALLED '7D. TANK CAPACITY IN GALLONS: v(� A 11. TANK CONTENTS IF(A.1),IS NARKED,COMPLETE ITEM C.IF(A.i),IS NOT MARKED,COMPLETE ITEM D. f-+ A. J2<MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ I UNLEADED ❑ 2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL C211 PRODUCT ❑ 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 A CA.&N CA.S.M: AIIA .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,A D TYPE A F �$INGLEWALUD ❑ 4 SECONDARY CON ANMENT 95 mogm SYSTEMTH MERIOR LINER a OTHER I SfEEL71igN ❑2 STWNESS SIEEL ❑ 3 FlBEAGIASS ❑ 4 STEEL CLAD W/Floon-IM NEIWORCED PLASTIC S. TANK ❑5 CONDEfE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%WTHMOLCOWADDLE FRP MATERIAL ❑ 9 BRONZE ID10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ %OTHER G INTERIOR ❑ 1 Rl1BBE uRm ❑2 ALKYD LINING ❑3 EPW LINING ❑4 PNENOIICUNING LINING ❑ 5 GLASS UNING �UNJNED ❑95 UNKNOWN ❑IS LINING RAISML COMPATIBLE WITH 1001LMEIHANOL? ❑YES ❑NO ❑ 99 OTHER D. CORROSION ❑ 1 PD.YERWFNEWRAP 2 TAO OR ASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑%UNKNOWN ❑ %OTHER IV. PIPING INF ORMAT ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND.BOTH IF APPLICABLE EAE TYPE AISUCTION A U 2 PgESSURE A U 3 GRAVITY A U 99 OTHER RUCTION A U I SINGLE WALLED A U 2 DOUBLEWALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U I STEEUIRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIOE(PVC) A U 4 FIBERGLASS PIPE AL A U 5 ALUMINUMA U 8 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 18 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 95 UNKNOWN A U MOTHER 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 S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S I ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMAT DATE LAST USED(MO/YR) 2. ESTIMATED UANTITY OF 3. WAS TANK ILLED WITH / SUBS A MAINING IN INER]!}L IAL? �YES ❑ NO GALLONS �V THIS PORM HAS BEEN COMPLETED UNDER PENALTY 4 PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY S JURISDICTION 1 AGENCY N FACILITY ID• TANK ID M UO r 3 I Uv I 6 CUP MT LOCAL AGENCY FACILITY 10• APPp PHONE F TH AREA CODE PERMIT NUMBER M. TA OVAL DA7E PERMIT EXPIRATION DATE / C� CHECK* PERMIT AYOUNT SI1RG RGE AMTf FEE CODE RECEIPT I BY: / Imo' FORM 8(3-7.BB) THIS FORM MUST BE ACCOMPANlaT A FACILITY/SITE APPLICATION. FORM 'A',UNLESS ktiwRENT FORMA' HAS BEEN FILED