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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION em COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - - Z MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 P ENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT E]6 TEMPORARY TANK CLOSURE TANK REMOVED Dq �ew FACIUTY/SITE NAME WHERE TANK IS INSTALLED: W S CS e FARM TANK-YES W-NO ❑ !V O I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CD A. OWNERS TANK IDX Un Kn 69J/7 B. MANUFACTURED BY: O C.YEAR INSTALLED JA KI14"f& D. TANK CAPACITY IN GALLONS: I II. 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 PETROLEUMB. C. ❑ 1 UNLEADED LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL E'1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS UNKNOWN ❑ 2 WASTE ❑7 METHANOL E]99 OTHER(DESCRIBE IN ITEM D,BELOW) ❑5 HAZARDOUS ❑80 EMPTY ❑ 95 D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF ' HAZARDOUS SUBSTANCE STORED&C.A.S.X C.A.S.M III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED MTH EXTERIOR LINER UNKNOWN SYSTEM ❑2 SWGLEWALEEO ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIFIBEAGIASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE [:]7 MINUM MATERIAL ❑ S 1W%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑1 RUBBER UNED ❑2 ALKYD UNING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING C. INTERIOR ❑5 GUSSLNNG ❑6 UNLINED 95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH TOM METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYnAfNEWRAP ❑2 TAR OR ASPHALT ❑3 WAP ❑ 4 FIBERGIASSREINFORCEDPUSTIC PROTECTION ❑5 CATHODIC PRDTECT04 ❑91 NONE ERiUNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U KNOWN 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 9 NKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM A U06NCRETE A U 7STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FAP A U 9 GALVANIZED STEEL A U 95 KNOWN A U 99 OTHER i V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. i P B 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P B S'PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 6 9 NKNOWN P S 99 OTHER VI. INFORMATION 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 GALLONSINERT MATERIAL? ❑YES E]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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION AGENCY# FACILITYID# TANKID# CURRENT LOCK AGENCY FACILITY 10# APPROVED BY NAME PHONE 0 WITH AREA CODE W&S rs 3 -S -'1,9 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK PERMITAMOUNT 1 �URCHABGE AMT. FEE CODE ^-CEIPT# BY: • FORM a(6-29-9e) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING_CQPY