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STATE OF CALIFORI-o _ WATER RESOURCES CONI 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 ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSEDT 10 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE [D,5'TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1 aVL FARM TANK-YES NO ❑ N Fj I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID W B. MANUFACTURED BY: to C. YEAR INSTALLED L D. TANK CAPACITY IN GALLONS: 5010 aa-kl- 11. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUMB. C. ❑ 1 UNLEADED ❑2 LEADED DIESEL F-13 CHEMICAL PRODUCT E]4 OIL PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS [-]5 HAZARDOUS ❑BO EMPTY [1]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.# CA.S.%: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,t D A TYPE OF ❑ 1 DOUBLE WAILED ❑3 SNGLEWAUED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SNGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEELARON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLAS IC B.TANK 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 A UMINUM ❑9100%METHANOL COMPATIBLE FRP MATERIALMATER ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNED ❑2 AIUNING ❑3 EPDXY UNING ❑ 4 PHENOLIC LINING C. LXYD LINING ❑5 GLASS UNING ❑6 UNUNEDUNKNGWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TARORASPHALT ❑3 V51. ❑4 FIBERGLASS REINFORCED PlASRC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UleuNKMM ❑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 91 NONE A 5 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 9/ NONE UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 RBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U CONCRETE A U 7 STEELCLAD W/FRP A U B 108%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A!U 195 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 5 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS W P 9 6 PREOSION TESTING P S 7 PRESSURE TESTING 8 91 NO P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED IMO/YR) 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN OIIl10N8 INERT MATERIAL? []YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGF-IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION R AGENCY R FACILITY ID M TANK ID# Eu = = loom 1=1 10161011 CURRENT LOCAL i O 7F CILITY IDN APPROVED BY NAMES 4L/7 PHONE M WITH AREA CODE PERMIT NUMBER CTJ 5 PERMITAPPROVALDA RMMIT EKP1IRA�TO•N DATE CHECK# PER MIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTN BY: FORM e(e 29 88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPti