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STATE OF CALIFORN' WATER RESOURCES CONTR BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM : � µ TANK TANK PERMIT APPLICATION INFORMATION m..�,.'�'o COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. — z MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑7 P MANENTLY CLOSED TANK 10 ONE ITEM ❑2 INTERIM PERMIT ❑ q AMENDED PERMIT ❑8 TEMPORARY TANK CLOSURE TANK REMOVED D FACILITY/SITE NAME WHERE TANK IS INSTALLED: OD JV, J(� G FARM TANK-YES O ❑ IV I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY -Alk- A. A. OWNERS TANK ID HC)MANUFACTURED BY: -� O C. YEAR INSTALLED ( D. TANK CAPACITY IN GALLONS: OQ II. TANK ONTENTS 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 PRODUCT ❑4 GASOHOL ❑5 JET FUEL ❑8 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&C.A.S.If C.A.S.#: 111. TANK CONSTRUCTION MANOkONEITEM ONLY IN BOX A B,C,&o A.TYPE OF ❑-I DOUBLE WALLED IN3 SINGLE WALLED WITH WIERIOR UNFA ❑95 UNKNOWN SYSTEM ❑2 SINGLE WAILED SECONDARY CONTAINMENT ❑99 OTHER ❑1 STEEIARON ❑ 2%NLERIS STEEL ❑3 FlBEAGLASS ❑q STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 L CHLORIDE ❑7 ALUMINUM ❑81 DD%METHANOL COMPATIBLE FRP MATERIAL9 BRONZE ❑1IZm STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RIBBERUNED ❑2 ALKYD LIN G ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHA140 ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF NDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 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 A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM A U 6CONCRETE A USTEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U THER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECOND RY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 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 ON8 SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES E]NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST kMY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY M COUNTY* JURISDICTION# AGENCY# FACILITY ID M TANK ID# M = = 10 161 10063 CURRENT COME AO Y FAC,;m ID# APPROV PBY NAME L�><j PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# Y. 1 wars Plc-29-88% THIS FORM MUST BE ACCOMPA BYA FACILITY/SITE APPLICATION, FORM`A',UNLESS AIAARENT FORMA' HASBEENFILED DATA PROCESSING COPY