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STATE OF CALIFORNIA WATER RESOURCES CONTROL 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/� ❑ I NEW PERMIT F-13 RENEWALPERMIT .CHANGE OF INFORMATION r eERMANENTLY CLOSED TANK ONE ITEM C/ / ❑ 2INTERIM PERMIT ❑ 4 AMENDEDPERMR ❑6 TEMPORARY TANK CLOSURE /TANK REMOVEz FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1 �� FARM TANK-YES❑ NO LW Z 1© I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID S 4 I B. MANUFACTURED B C L!>� C. YEAR INSTALLE 7 ,lid D. TANK CAPACITY IN GALLON p 11. TANK CO TENTS 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. !t G ❑ 1 UNLEADED LEADED ❑ 3 DIESEL ��1! ❑3 CHEMICAL PRODUCT ❑4 OIL � 1 PRODUCT ( ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑T METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF C.A.S.N ', r HAZARDOUS SUBSTANCE STORED&C.A.S. XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTE �(� ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER L CLAD IBERGLASS B.TANK ® ❑ 5 C014CflElE ❑fi POLYVIEHYL SS CH 0 DE ❑7 ALEL 3 UMINUM ❑S 100%%METHANOL COMPATIBLEEINFRFOIK;ED PLASTIC MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEELUNKNOWN ❑99 OTHER ❑ 1 RUBSERUNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING C. NLINING G ❑ 5 GLASS LINING ❑6 UNUNED rp�NKNDWN ❑ IS UNING MATERIAL COPATIBLEWTTH IOD%METHANOL 1 ❑YES ❑NO ❑99 OTHER D. CORROSIO ❑ 1 POLYETHIENEWPAP ❑ 2 TARORASPHNLT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ffkS<NKNGWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE n A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER tJ un B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U UNKNOWN A U 99 OTHER /� //l A U 1 STEEUIRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE IPVC) A U 4 FIBERGLASS PIPE C. MATERIAL 6 A U 5 ALUMINUM A U��6CONCRETE A U T STEEL CLAD W/FRP A U 6100%METHANOL COMPATIBLE RIP p A U 9 GALVANIZED STEEL A ')95 UNKNOWN A U 99 OTHER V. &K DETECTION SYSTEM CIRCLE PFOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. y n $ 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3VADOSE WELLS P S J ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS l� P S fi PRECISION TESTING P S ] PRESSURE TESTING O91 NONE 5 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH .W SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO Z 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 -7.5 .COUNTY N JURISDICTION N AGENCY N FACILITY 10 N D7 TANK ID N 3 Iola 8 C� c� AC I C NT LOCAL AGENCY FACILITY 1D N AP VIED BY NAME PHONE N WITH AREA CODE E z PERMIT NUMBER MITAPPROVALOATE PE IT PIRATIOND Xtl CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORM B 13-L-36; THIS FORM MUST BE ACCOMPANI A FACILIITY/SITE APPLICATION, FORM 'A',UNLESS A2ERRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY