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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM B': UNDERGROUND STORAGE TANK PROGRAM - TANK TANK PERMIT APPLICATION INFORMATION "m f^^ COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 P ANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED tj 17 FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NOr�f N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CA) F—& A, OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 2rD II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL F—] 2 PETROLEUM B C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL F-] 3 CHEMICAL PRODUCT F-] 1 P 4 OIL RODUCT ❑ 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&C.A.S.k /V Q C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D I UBLEWALLED F-]3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN A TYPE OF ❑ SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER STEEL/IRON 2 STAINLESSSTEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑8 IN%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR I RUBBER LINED ❑ 2 KYDUNING F__] 3 EPDXYLINING ❑ 4 PHENOLICUNING LINING ❑ 5 GLASS LINING Leol 6 UNLINED ❑ 95 UNKNOWN A / ❑ IS LINING MATERIAL COMPATIBLE WITH IORMFTHANOL7 ❑YES ❑ NO OTHER D.CORROSION ❑ 1 POLYETHLENEWRAPn�'fAR OR ASPHALT F-1ARWRAP 1:14 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION rum- "91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMAT ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION ALU SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL AALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A 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. 4 )6 P 5 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S fi PRECISION TESTING P S 7 PRESSURE TESTING 91 NONE P 5 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DAT LAST USED(MO/YR) 2. ESTIMAT D QUANTITY OF 3,Wo TANK FILLED WITH /i✓ SUBS REMAINING IN GALLONS MATERIAL'S E]YES [:] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KN LEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY k FACILITY ID R TANK ID M zp I / I t?10 103 CURRENT LOCAL AGENCY FACILITY 10 N APPROVE BY NAME ` PHONE M WITH AREA CODE E LJf— /V� -Zg/75 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE flECEIPT N BY: FORM B(6-29-8B) THIS FORM MUST BE ACCOMPANIE 1 A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A t, RENT FORMA HAS BEEN FILED DATA PROCESSING COPY