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STATE OF CALIFORNI WATER RESOURCES CONTRC IOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM a TANK TANK PERMIT APPLICATION INFORMATION COMPL A SEPARATE FORM WITH THE FOLLOWIN0 INFORMATION FOR EACH TANK. I i0 MARK ONLY EW PERMIT ❑ 3 RENEWAL PERMIT �5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO AN ONE ITEM INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED LJ FACILITY/SITE NAME WHERE TANK IS INSTALLED: F FARM TANK-YES NO W IV I. TANK DESCRIPTION COMPLETE ALL ITEMS—IF UNKNOWN—SO SPECIFY 00 A. OWNERS TANK 10 p 0 7 1 B. MANUFACTURED BY: T C. YEAR INSTALLED 4' 3 O. TANK CAPACITY IN GALLONS: 10, vO U 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. I MOTOR VEHICLE FUEL ❑ 2 PETROLEUMR. C ❑ 1 UNLEADED ❑ 2 LEADED DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL , PRC ❑ 4 GASAHOL ❑ 5 JET FUEL [-] 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY [:]95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM O,BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.N � C A.S.I: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,&D A.TYPE OF ❑ I SUE WALLED ❑ 3 SINGLE WALLED NTH EXTERIOR U14ER ❑95 UNKNOWN SYSTEM 2 SINGLF WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER 25 1 STEEUION ❑2 STAINLESS STEEL ❑3 RBERGUSS ❑ 4 STEEL CUD WIFIBERGLASS RDNFORCEO PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYWM CHLORIDE ❑ 7 ALUMINUM ❑ 8 1910%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 19 GALVANIZED STEEL ❑%UNKNOWN ❑ 99 OTHER C. INTERIOR L] I RUBBER UNED F] 2AMiD LINING ❑3 EPDXY UNNG ❑ 4 PHENOUC LINING LINING ❑ 5 GLASS LINING Ef 6 UNLINED ❑% ❑ ISUNINGMATOULCOMPATIBLEMTHII011METFWA? ❑YES [:] NO %OTHER jefol /v D. CORROSION ❑ 1 POLYETHEWWRAP 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 RBERGASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODICPHOTECTION ❑ 91 NONE ❑ %UNKNOWN ❑99 OTHER IV. PIPING INFORM ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U W OTHFR A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 11 6 CONCRETE A U 7 STEEL CUD W/FRP A U 8 IOD%METHANOL COMPATIBLE FRP A U 9 GALVANIZEOSTEEL A v 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 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 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. ESTIMATED DATEST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAST NK FILLED WITH l ) SUBSTNO INING IN E TERIAL? ❑YES ❑ GALLONS THIS FORM kAS BEEN COMPLETED UNDER PENALTY OF P RJURY,AND TO THE BEST OF MY KNOWL DGE.IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY B JURISDICTION M AGENCY S FACILITY IDS TANK ID N s / Ilolo 10 3 CURRENT LOCAL AGENCY FACILITY ID 4 %PPR BT YE PHO Et WTTHM COO �J T7 6t-2^2 PERMIT NUMBER PE ITAINMOVALOATLf PERMIT EKFIRATION DAllf �/ CHECK A PERMIT AMOUNT SURCHA GEA 1 FEE CODE ` --CEIPT• BY: FORM B(8 n-w) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UM_ \CURRENT FORM-N HAS BEEN FILED DATA DRnCFeclNr.rnPV