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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION Y; COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ' MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑/ AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑R TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: '�G; f��IIJ�fTi:L�� FARM TANK-YES❑ NO z 1. TANK DESCRIPTION COMPLETE ALL ITEMS-If UNKNOWN—SO SPECIFY .p A. OWNERS TANK ION B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: J 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. 0 ClY A. ❑'1-MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED LEADED ❑ 3 DIESEL 3 CHEMICAL PRODUCT ❑t OIL ❑1 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 6 C.A.S.N CA.S.N: Ill. TANK CONSTRUCTION MARKONE ITEM ONLYIN BOXA,B,C,&D A TYPE OF ❑ I DOUBLE WAILED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED 1 SECONDARY CDNTANMENT 99 OTHER ❑ I STEEUtlgN ❑2 STAINLESS STEEL El FIBERGLASS ❑ 6 STEEL CLAD W/FIBERGLASS REINFORCEDPLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE MATERIAL E37 ALUMINA ❑6100%METHANOL COMPATIBLE FRP ❑9 BIDNZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ' C.INTERIOR ❑ I RUBBEAUNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑A PHENOLIC LINING LINING ❑5 GLASSUNING ❑6 UNUNEO ❑95 UNKNOWN ❑ IS LINING MATERUL COMPATIBLE WITH 100%METIWIOL7 ❑YES ❑ NO 99 OTHER D. CORROSION ❑ 1 POLYETMENEWRAP 2 TM OR ASPIMLT ❑3 VINYL WRAP ❑1 FIBD7GL SSREINFORCEDPLASTIC PROTECTION ❑5 CADMOPROTECTION ❑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 f SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U H FIBERGLASS PIPE A U 91 NONE G MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A' U 7 STEELCLAOW/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL 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 B 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P B 1 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING P 8 7 PRESSURE TESTING P B 91 NONE P B 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE f.ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED OUANTITY OFTANK FILLED WITH GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES [—] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE L LOCAL AGENCY USE ONLY COUNTYI JURISDICTION I AGENCY I FACILITY ID I TANK 10 N CURRENT LOCAL AGENCY FACILI'IDI APPROVED eY NAME PHONE I WITH MEA CODE \ F RMR NUMBER PERMIT APPROVAL DATE PERMIT EKPIRAnON DATE I CHECKI MIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT/ �? er: �� J FORM 8(Bd9-0e),T1yS FORM MUST BE ACCOMPANIE AFACILITY/SITE APPLICATION, FORM 'A',UNLESS AtiriRENT FORMA' HAS BEEN FILED \ v \ 'a_ Ll DATA PROCFS61141 , Cnov