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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM m �; TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. I ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY C K ❑ 3 RENEWAL PERMIT ❑B TANK REMOVED MARK ONLY ❑ �PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSUR ONE ITEM IF 2 INTERIM PERMIT FARM TANK•YES❑ NO 01 FACILITY/SITE NAME WHERE TANK IS INSTALLED: N (h1 vI^ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY ANUFAGTURED BY: A. OWNERS TANK ID# ' 'zoo o D. TANK CAPACITY IN GALLONS: C.YEAR INSTALLED 11. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),ISNOT MCRKED,1 UNLEADED E ITEM 2 LEADED ❑3 DIESEL A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. 1 PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL 6 AVIATION GAS ❑ ❑3 CHEMICAL PRODUCT ❑ 4 OIL 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) ❑5 HAZARDOUS E]80 EMPTY E]95 UNKNOWN El2 WASTE ❑ D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: HAZARDOUS SUBSTANCE STORED 8 C.A.S.k III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,S D ❑95 UNKNOWN ❑i OUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER A.TYPE OF q SECONDARY CONTAINMENT ❑99 OTHER SYSTEM 2 GLEWALLEO ❑ 1 STEELIIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑/STEEL CIADWIFIBERGlASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER US' ❑2 ALKYD LINING ❑3 EPDXY LINING ❑�Ek4 ENOLIC LINING C. INTERIOR 6 UNLINED 95 UNKNOWN LINING ❑SOLASS LINING ❑ ❑ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO 99 OTHER 1 POLYEIHLENE WRAP 2TAR OR ASPHALT LWRAF ❑4FIBERGlASS REINFORCED PLASTIC D. CORROSION ❑ ❑ ❑ PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN 99 OTHER IV. PIPING INFORMATION CIRCLE AIF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLETl -ONE A U 95 UNKNOWN A U 99 OTHER A. SYSTEM TYPE AlU 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY 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 U 3 POLYVINYL CHLORIDE(PVC) A U q F00%M METHANASSPIPEOL A U LE NONE C.MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 5 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY.OR S FOR SECO�DARYAMARY LEAK DETECTION SYSTEM MUST BE CIRCLED.L1 VISUALCHECK 8 21NVENTORY RECONCILIATION P 6 3VAOOSE WELLS ONIC MONITOR V 9 99GOTOHER UND UND WATER MONITORING WELLS0 P 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE OWN VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3 WAS TANK FILLED WITH 2. ESTIMATED QUANTITY OF INERT MATERIAL? []YES ❑ NO 1.ESTIMATED DATE LAST USED(MO/YR) SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND Tb'THE BES7 OF MY KNOonTE DGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY TANK ID# COUNTY# JURISDICTION AGENCY# FACILITY ID# E= C� � C;J APPROVED BY NAME PHONE#WITH AREA CODE CURRENT LOCAL AGENCY Lr•/{I`l'�i FAGIL44Y VJks PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT NUMBER / SURCHARGE AMT. FEE CODE ECEIPT M 9C `O \ CHECK# PERMIT AMOUNT y��li0 FORMB(6-29-88) THIS FORM MUST BE ACCOMPANIEDBY A FACILITY/ DSIATTAAPPLRIO RA',UNLESSACURRENT FORMA' HAS BEEN FILED OCESSINGCGP -