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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION (az TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT 4 AMENDED PERMIT 1�71 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO Ca I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 00 A. OWNERS TANK IDN L y,. -77TB. MANUFACTURED BY: CD C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: ( � II. TANK C04TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. L�J1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL B. DUCT ❑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 OFMet HAZARDOUS SUBSTANCE STORED&C.A.S.A C.A.S.9: III. TANK CONSTRUCTION MARK ONE REM ONLY IN BOX A,B,C,8 A.TYPE OF ❑ I DOUBLEWALLED ❑3 SINGLE WALLED WITH IXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CULL W/RBFAGLASS REINFORCED PLASTIC B. TANK MMATERIALF-15 CONCRETE ❑6 POLYVINYLCHLORIDE F-]7 ALUMINUM ❑810M METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ M UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBERUNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑5 GLASS LINING ❑6 UNUNED ❑ 95 UNKNOWN ❑ IS LINING MATERMLCOMPATIBLE WITH 10096 METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 WNYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODICPROTECMON ❑91 NONE ❑95 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 91 NONE A 95 UNKNOWN A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE U 95 UNKNOWN A U %OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 9/ NONE C. MATERIAL A U 5 ALUMINUM A CONCRETE A U 7 STEELCLADW/FRP A U B 1I METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 1 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USEq(T/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH „e /f GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES [:] NO THIS FORM HAS BELN 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 N JURISDICTION# AGENCY P `� FACILITY ID R TANK ID# --I- 3 �- O cv CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY NAME PHONE N WITH AREA CODE �6 PERMIT NUMBER PERMIT APPROVAL DATE rfiRMIT E RATION DA \p\\\\ \ CMECKF PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: ^ \� (FORM B S-29-m) THIS FORM MUST BE ACCOMPANI�"Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A MRRENT FORM'A' HAS BEEN FILED