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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!NFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PE IMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED I FACILITY/SITE NAME WHERE TANK IS INSTALLED: Adlrfi& zs7rlleex1 FARM TANK-YES❑ NO Fri- I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY IO A. OWNERS TANK ID# B. MANUFACTURED BY. C. YEAR INSTALLED I C b 0 U. TANK CAPACITY IN GALLONS W 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPTE ITEM D. A. 1 MOTOR VEHICLE FUEL F—] 2 PETROLEUM e C. ❑ I UNLEADELED 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL 1 UCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS E]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 CA.S.# TomC.A.S.W N .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,8 D A.TYPE OF ❑ 1 DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM �SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑1 STEELARON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 AL INUM ❑S 1D0%METHANOL CDMPATIBLEFRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑W OTHER C. INTERIOR F-11 RUBBERUNED ❑2 ALKYD UNING ❑ 3 EPDXY LINING ❑4 PHENOUC UNING LINING ❑5 GLASS LINING ❑6 UNLINED KNOWN ❑ISUNING MATERIAL COMPATIBLE NTH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHIENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER I B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AU)5 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 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S I PRECISION TESTING P S 7 PRESSURE TESTING P S NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED MO/YR) 2. ESTIMATED QUANTITY OFOILLLONB 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES [:]NO THIS FORM HAS BEA 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 CCIDU)NTTTYY/# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CUR LOCAL AGENCY FACILITY ID a APPROVED YNAM PHONE N WITH AREA CODE 9 PERMIT NUMBER PERMIT APPIIOVAL DATE RMIT EXPHYTION DATE ` CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT k BY: FORM B(3-]-BB) THIS FORM MUST BE ACCOMPANIED A FACILITY/SITE APPLICAnON, FORM 'A',UNLESS A 6XRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY