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STATE OF CALIFORNIA WATER RESOURCES CONTR(--90ARD FORM 'B': UNDERGROUND STORAGE TANK PR6 RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING I FORMATION FOR EACH TANK. Z i MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM F-] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT n 6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED / FACILITY/SITE NAME WHERE TANK IS INSTALLED: "L (J C�tFARM TANK-YES❑ NO lll (V N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY /� Q1 A. OWNERS TANK IO N OZ B. MANUFACTURED BY: GY4ac C. YEAR INSTALLED L(/'- D. TANK CAPACITY IN GALLONS: &VDD II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A,1),IS NOT MARKED,9OMPLETE ITEM D. i A. 02.1 OTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. PIET1 UNLEADED F] 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 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&C.A.S.R C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,B D A.TYPE OF ❑ 1 UBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLEWALIFD ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEUIRON ❑2 STAINLESS STEEL ❑ 3 RBERGLASS ❑4 STEELCIADW/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE F-] 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ I RUBBBLLINED ❑2 AURDUNING F-13 EPDXY LINING ❑4 PHENOLICUNING C. INTERIOR ❑5 GLASS LINING E�6 UNUNED ❑95 UNKNM _ (- [-] ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES [-] NO OTHER �(,4A/K� D. CORROSION ❑ 1 POLYEIHLENE WRAP ❑2 TANORASPHALT ❑3 LWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION E] 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A 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 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 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A8 CONCRETE A U 7 STEEL CLAD W/FFIP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A UNKNOWN A U 99 OTHER { LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS J 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 1. ESTI TED DATE LAST USED(MO/YR) 2. ESTIMATED OLIANTITY OF 3.WAS TANK LLED WITH SUBSTANCE R A GIN INERT L? [:]YES [-] NO GALLONS A 00I. THS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION k AGENCY N FACILITY IDN TANK ID N CURRENT LOCAL LAAGENCY FACILITY ID N APPROVED BY NA �/ PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE ERMIT PIR IONDATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT* BY: /,f RM B(6-11-1) THIS FORM MUST BE ACCOMPANI Y A FACIL mss APPLICATION, FORM'A',UNLESS - FORM'A' HAS BEEN FILED (> t/'/.6 DATA PROCESSING COPY