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STATE OF CALIFORPDE% WATER RESOURCES CONTROL. BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM s: TANK PERMIT APPLICATION INFORMATION TAN CO LETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CL NK ONE ITEM El INTERIM PERMIT F-14 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: �4(7�U FARM TANK-YES MNO i 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 'r " A, OWNERS TANK ID# B. MANUFACTURED BY: v C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: V DV L,f 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. Co A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED Z LEADED DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL 0 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN 2 WASTE p 7 METHANOL 99 OTHEH(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# G.A.S.k, x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,&D A.TYPE OF El 1,9CUBLE WALLED F-1 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM Ok"2"SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER 1 STEEL/IRON F-1 2 STAINLESS STEEL F-] 3 FIBERGLASS 4 STEEL CLAD W;FIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE F-] 6 POLYVINYLCHLORIDE V95 LUMINUM 8 100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE El 10 GALVANIZED STEELUNKNOWN 99 OTHER I RUBBER LINED �-] 2 ALKYD LINING Q 3 EPDXY LINING 4 PHENOLIC LINING C. INTERIOR LINING 5 GLASS LINING F�6 UNLINED 95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL' �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 V995 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 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 1 CG%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AG) 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. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 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 ONO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED$SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3 I I El F1 I Q !� / v/ 131 Eo 10 1 ol CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA C IPERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SIiRCHARGE AMT. FEE CODE RECEIPT# BY: dB l A Fo WREN FORM B(3a-5a) THIS FORM MUST BE ACCOMPANWSY A FACILITY/SITE APPLICATION, FORM 'A',UNLESJ&IRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY \