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STATE OF CALIFORNIA -- WATER RESOURCES CONTROL ARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM m� TANKTANK PERMIT APPLICATION INFORMATION COMP E A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z :O MARK ONLY 1 NEW PERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLYCLOSE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED O I N ' FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO a► W4 I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOW —SO SPECIFY CA) A. OWNERSTANKID# MANUFACTUR /' B. ED BY: Cw) C. YEAR INSTALLED //(j`�/ D. TANK CAPACITY IN GALLONS 000 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A_ 1 MOTOR VEHICLE FUEL F-12 PETROLEUM B. C1. UNLEADED L:] 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑4 OIL RODUCT ❑ 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 OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.# C.A.S.W III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BORA,0,4,&D BLE WALLED F-1 3 SINGLE WALLED WITH WN A TYPE OF I SYSTEM 2 SSIINGLE WALLED F]4 SECONDARY CONTAINMENT LINER ❑99 OTHER ❑ 1 STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL DIAD W/RBERGLASS REINFORCED PLASTIC L TANKF-1 5 CONCRETE ❑6 POLYWNYL CHLORIDE ❑7 AL ❑81 DD%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHE LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑6 UNLINED UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%MEfHANOL? ❑YES ❑ NO THER D. CORROSION ❑ 1 POLYETHLENEWMP ❑2 TARORASPHALT ❑ 3 VI RAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION E]91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN 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 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM AV= A U 7 STEEL CIAO W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 0VIP S 1 VISUALCHECK �8 2 INVENTORY RECONCILIATION P 8 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 9W6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P S 99 OTHER . INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE_AS7 USED(MO/YR) 2. ESTIMATED QUANTITY OF3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3Es CURRENT LOCAL AG jjCY�FAC/ILIT/Y'ID N APPROVED BY NAME PHONE#WITH AREA CODE ,3 -2 - PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION CHECK# PERMIT AMOUNT SURCHARGE ANT. FEE CODE RECEIPT BY: FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIE"Y A FACILITY/SITE APPLICATION, FORM `A',UNLESS A,_.,NIENT FORMA' HAS BEEN FILED DATA PROCESSING COPY