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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 INFORMATION FOR EACH TANK. - MARK ONLY ❑ I NEWPERMIT ❑G RENEWALPEAMIT. E�S-CHANGE OF INFORMATION ❑ /PERMANENTLY CLOSE ONE ITEM ❑2 IWERIMPERMIT ❑A AMENDED PERMIT ❑5 TEMPORARY TANK CLOSURE ❑B TANK REMOVED (� FACILITY/BITE NAME WHERE TANK IS INSTALLED: s Y` FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IO N O� 3 B. MANUFACTURED BY: ("C.YEAR INSTALLED U D. TANK CAPACITY IN GALLONS: 2 c o v II. TANK C_ONTENTS IF(AL1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A t MOTOR VEHICLE FUEL ❑ 2 PETROLEUM - C. F] 1 UNLEADED 2 LEADED C]9 DIESEL f-1B. I PD CHEMICAL PRODUCT 1 OIL 90OWT ❑ 1 GASAHOL S JET FUEL ❑B AVIATION GAS ❑ S HAZARDOUS ❑ SO 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 C.A.S.I C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,10 A TYPE OF ❑ I Wj6cEwAu.EO ❑0 SINGLE WALLED MTH EXTERIOR LEER ❑95 mm" SYSTEM Ea2 S ALIFD ❑1 SEMIDAWCONTANMENT ❑ 99 OTHER 1 SFEELRON F-12 STAINLESS STEEL F-13 FIBERGLASS ❑A STEEL CUD W/FIBEAGIASS REINFORCED PU9TK; B.TANK MMATERIAL [-]5 CMD" ❑ 9 POLYVINYL CMORIOE ❑ 7 ALUMMIM ❑I IOD%METHANOLCOIIPATIBLEFRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNXNOYM ❑ 99 OTHER C.INTERIOR ❑ I RIIBBFAIIIIED ❑2 LINING ❑7 EPDXY LINING ❑1 PHENOUCUHMG LINING ❑5 GASSUMNO Lfffi UNUNED ❑95 UNKNOWN ❑B lNINO LUIFAUL C0IYATIBLE WITH 100% 7 ❑YES ❑ND ❑99 OTHER D.CORROSION ❑ 1 POLYETHAENEWRAPION ❑2 OR ASPHALT ❑9 VINYL WRAP ❑ 1 RBEROLASSREWORUDPIASTIC PROTECTION ❑5 CAIHOGC PROTECT91 MINE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A ti7i SUCTION A U2 PRESSURE A U B GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A NGLE A U 2 DOUBLE WALLED A U 9 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A - STEEL/IR A U 2 STAINLESS STEEL A U 9 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U ( CONCRETE A U 7 STEEL CUD W/FRP A U 8 I0 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 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. t I VISUAL CHECK P t 2 INVENTORY RECONCILIATION P t 2 VADOSE WELLS P B A ELECTRONIC MONITOR P t S GROUND WATER MONITORING WELLS t. B PRECISION TESTING F t 1 PAESSURE TESTING P t 91 NONE P B 95 UNKNOWN P t 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF d WAS TANK FILLED WITH U �ti.uc✓•`_ SUBSTANCE REMAINING IN �� INERT MATERIAL? ❑YES GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED L SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION f AGENCY I FACILITY ID I TANK 10 N v SI S S U o 1 c) -3 CURRENT LOCK AGENCY FACILITY 1D# APPROVED BY NAME PHONE I WITH AREA CODE '604sq /-� PERMRNUMBER . PERMITAPPROVAL DATE PERMIT EXPIRATION DATE 1\\� CHECK# PERMIT AMOUNT 4URCMARGE AMT. EF CODE ryECEIPT E By. F �� 1�5