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STATE OF CALIFORNF 1. WATER RESOURCES CONTP BOARD FORM `B': UNDVhGROUND STORAGE TANK PROtRAM TANK TANK PERMIT APPLICATION INFORMATION ® b COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. -- MARK ONLY ❑ I 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 ❑8 TANK REMOVED 5 FACILITY/SITE NAME WHERE TANK IS INSTALLED: e,Q 1 FARM TANK-YES U NO ❑ O I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID B. MANUFACTURED BY: Lf X- C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 31 OL IL TANK C NTENTS IF(A.1),18 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITENtAAO? A. Ej�KMOTCIR VEHICLE FUEL ❑2 PETROLEUMB C. ❑ 1 UNLEADED DED ❑3 DIESEL F-13 CHEMICAL PRODUCT ❑4 OIL _ PRODUCT 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.# J - - CA.S.#: I 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C.8 D A TIRE OF —11 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM EgIrSINGLE WALLED ❑4 SECONDARY COMAINMENT ❑99 OTHER EKMARON ❑2 STAINLESS STEEL ❑ 3RBERGLASS ❑4STEEL CLADW/FIBEROUSS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER LINED ❑2 ALM LINING ❑ 3 EPDX1'LINING ❑4 PH UC LINING LINING ❑ 5 GLASS LINING F-1UNKN 6 UNLINED OWN ❑ ISUNING MATERIAL COMPATIBLE WITH IOD%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2TAR OR ASPHALT ❑ 3M WRAP ❑4 FIBERGLASS REINFORCED PLASTIC /- PROTECTION El5 CATHODICPROTECRON ❑91 NONE 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 ACU_'05 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 A U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLWIWLCHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A095 UNKNOWN A U 99.OTHER V. LEAK DETECTION SYSTEM CIRCLE P FO PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1VISUAL CHECK IP S 2 INVENTORY RECONCILIATION P 8 3VADOSE WELLS 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO7YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES [—] NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,ST' AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY TANK ID# sr 3 DDD / CURRENTLO Y FACILITY IDM APPROVED BY NAPE ` -p PHONE N WITH AREA CODE / T/� PERMIT NUMBER PERMIT APPROVAL DAIP PERMIT EXPIRATION DATE CHECK PERMIT AMOUNT SURCHARGE AMT. FEECODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOM I AFON, FORM'A!,UNLESS A O NRE RMW HAS BEEN FILED DATA PROCESSING COPY