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STATE OF CALIFORtdIA WATER RESOURCES CONTROL ')ARD FORM 'B': UNDERuROUND STORAGE TANK PROD-nAM TANK TANK PERMIT APPLICATION INFORMATION % COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - O MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL �- ONE ITEM ❑2 INTERIM PERMIT ❑ 1 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED g/ FACILITY/SITE NAME WHERE TANK IS INSTALLED: O 0 �US� / FARM TANK-YES NO F-1f V I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK IDN B. MANUFACTURED BY: L IK C. YEAR INSTALLED (_ D. TANK CAPACITY IN GALLONS: U 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. G ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 1 OIL ❑ 1 PRODUCT ❑ T GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS r ❑5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER IDESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CAS.N CA.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C.AD A TYPE OF ❑ I DOABLE WALLED ❑3 SINGLE WALLED WITH EXTFROR UNER ❑95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑1 SECONDARY OWAAMM ❑99 OTHER ❑ I ST UIRON ❑2 STAINLEMOR ❑3 RBBIGUI55 ❑ A STEEL CUD W/FIBERGlA4S REINFORCED PLASTIC B.TANK MATERIAL ❑ 5 CONCRETE ❑6 POLYVOLYLCWOR X ❑7 A-AINMW ❑ B 100%METHANOL COMPATIBLE FRP -. ❑ 9 BRONZE ❑ 18 GALVANIZED SIFH ❑95 IAIKN0IYN ❑ 99 OTHER F-11 RIBBER IRE1 ❑ 2 ALKYD LINING 3 EPDXY LNNG ❑/PHENOLIC UMNG G UNINGIOR ❑ 5 Di"LNING ❑6 UNJNED ❑95 UNKIYAYII ❑ 6 WING WTERAL COEPATIBLE WIN I00%MLT M%? ❑YES ❑No ❑99 OTHER D. CORROSION ❑ 1 POLYETREI✓EWRAP ❑2 TARORISRMLT ❑3 VINYL WRAP ❑A FIBBiGUSS REINFORCED PLASM PROTECTION ❑5 CATHOMPROTEC ION ❑91 NON: ❑95 wma ❑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 A U 95 UNKNOWN A U %OTHER S.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 W OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U N FIBERGLASS PIPE A U 91 NONE G MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FAP A U 8 100%METHANOLCOMPATIBLEFRP 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 1 VISUAL CHECK P t 2 INVENTORY RECONCILIATION P t 3 VADOSE WELLS P t A ELECTRONIC MONITOR P t 5 GROUND WATER MONITORING WELLS t 8 PRECISION TESTING P t 7 PRESSURE TESTING P t 91 NONE P t 95 UNKNOWN P t W OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE UST ILED(MO/YR) 2. ESTIMATEDQUANTITYOF 3. WAS TANK FILLED WITH SUBSTANCE REMAINOALLOMt REMAINING W INERT MATERIAL? EDYES EDNO i I- THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPucANrs NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY JURISDICTION N AGENCY N FACILITY ID N TANK ID N V / I 1 5 CURRENT LOCAL AGENCY FACUJTY M F APPROVED BY NAME PHONE F WITH AREA COOS O4-zZ,:?3 PERMIT HUMS" PERMIT APPROVAL DATE PERMIT EILPIRATION DATE 9 ) k CHECK/ PERWTAYOUM SURCHARGE AMT. FEECODE v-^EIPTO BY: MRM B i&naBN THIS FORM MUST BE ACCOMPANIED in-A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED Dere PQnrPcc Mrl rnDV