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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM ' 4 TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. »tl MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE Ej 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: /D30(p h FARM TANK-YES❑ NO •Q I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID R B. MANUFACTURED BY: C. YEAR INSTALLED ( D. TANK CAPACITY IN GALLONS: �C 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 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 pflpppCT 4 GASAHOL 5 JET FUEL 6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY 5 UNKNOWN [:1 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.R C.A.S.R: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑i DOUBLE WALLS) ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER F-11 STEBUTION ❑2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE L]6 POLYVINYLCHLORIDE ❑;ALUMINUM 0 8100%METHANOLCOMPATI8LEFRP ❑9 BRONZE 10 GALVANIZED STEEL V95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ i RUBBER UNED 2 AUCYD LINING ❑ 3 EPDXY LINING ❑kfHENOUC LINING LINING ❑5 GLASS UNING ❑6 UNUNED 1995 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑W OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TARORASPHALTINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION [-]5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN W 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 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEO TRENCH A U 91 NONE Q 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 9/ NONE C. MATERIAL A U 5 ALUMINUM ONCRETE A U 7 STEELCLADW/FRP A U 8109%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STE A 5 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 8 3 VADOSE WELLS P 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P 8 5 UNKNOWN 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 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. APPLICANTS NAME(PRINTED&SIGNATURE) DATE I LOCAL AGENCY USE ONLY COUNTY M JURISDICTION R AGENCY X TANK ID A �COay7 � RRENT LOCAL AGENCY FACILITY 10 N APPROVED BT N PHONE N WITH AREA CODE U16AST T NUM R PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKM PERMITAMOUNT SURCHARGEAMT. FEE CODE RFCEIPT0 BY: dCA FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIEDWA FACILITY/SITE APPLICATION, FORM'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED DR 'I PROCESSING COPY