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STATE OF CALIFORNY WATER RESOURCES CONTF BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT Eft CHANGE OF INFORMATION ❑7 PER NENTLY CLOSED TANK ONE ITEM F__12 INTERIM PERMIT F-] 4 AMENDED PERMIT El6 TEMPORARY TANK CLOSURE ❑ NK REMOVED N FACILITY/SITE NAME WHERE TANK IS INSTALLED: L)- Inq Q FARM TANK-YES ❑ NO A N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N A. OWNERS TANK ID# I I B. MANUFACTURED BY: u.n L/)G1,4j n C. YEAR INSTALLED LkA') Ic:/'1CLOY\ D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. CL] UNLEADED ❑ 2 LEADED 913 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL 91 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&CAS.# C.A.S.#: -� III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,S,C,&D A. TYPE OF ❑ i DOUBLEWALLEO ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM vAll SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 RBE%LASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑810016 METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL 5jT95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER UNE ❑2ALK1'D LINING ❑3 EPDXY UNING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNUNE E995 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 10D%METHANOL? ❑YES ❑ NO [�j97OTHER 1.4L D. CORROSION ❑ 1 POLYETHLENEWRAP ,❑2TAR OR ASPHALT ❑ 3VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION IRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U f SJCTlq_V A U 2 PRESSURE A U 3 GRAVITY A U 9/ NONE A U 95 U 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 (Z5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CO A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CCIRCLE�P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 4NEORMATI`DN VISUALyHP�3` INVE'f NT^o+RP^^"^"'" io^' P 3 3 VADOSE WELLS P S d ELECTRONIC MONITOF 3 5 GROUNDWATER MONITORING WELLS fR -'-- STING 8 7 P 3 91 NONE P S 95 UNKNOWN P 3 99 OTHER ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH --� SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES [_ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# � = U z3 I St I cl I I d C) I Q CURRENT LOCAL�G%W FA5 TY f`IDN APPROVEp ECLJ PHONE#WITH AREA CODE NN NN l \1 PERMIT NUMBER PERMIT APPROVAL OAf9 PERMIT EXPIRATION DATE CNECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: �.l FORM B(6-29-88) THIS FORM MUST BE ACCOMPAMED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESY"CURRENT FORMA' HAS BEEN FILED