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STATE OF CALIFORNI WATER RESOURCES CONTR OARD FORM `B': UNDERGROUND STORAGE TANK PRO RAM o. , TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWALPERMIT E] 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLO E K ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE B TANK REMOVED �y FACILITY/SITE NAME WHERE TANK IS INSTALLED: 7 Ai. -/ L FARM TANK-YES O LyJ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: ,1 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Z o V OU 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 ROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ ❑6 AVIATION GAS 3 CHEMICAL PRODUCT M4 OIL PRODUCT ❑ 4 GASAHOL n 5 P FUEL ❑ 5 HAZARDOUS ❑ BO EMPTY ❑ 95 UNKNOWN 2 WASTE ❑ 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF �p HAZARDOUS SUBSTANCE STORED&C.AS.# as t 'l/ C A #: XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ I UBLE WALLED F-13 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 IOAMETHANOLOOMPATIBLEFRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER I RUBBER UNED ❑2 ALKYDUNING ❑3 EPDXY LINING ❑ 4 PHENOLIC UNI NO C. INTERIOR ❑ 5 GLASS LINING r 6 UNLINED ❑95 UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WTTHIp METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I 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 INFORMATiPN CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION AW, SINGLEWALLED A U 2 DOUBLEWALLED A U 3 UNEDTRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A LG6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 095 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. IR )Q�p S I VISUAL CHECK 2 INVENTORY RECONCILIATION AS 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS CP S 6 PRECISION TESTINGVS 7 PRESSURE TESTING 8 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1, ESTIMATE DA E ST USED(MO/YR) 2. ESTIMATE O ANTITY OF 3.WAS TANK FILLED WI H SUB A EF E WING IN INERT MATER L ❑YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF FIERJURY,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# FE[ q z, D O l CURRENT LOCAL AGENCY FACILITY 10 p APP O O BY AME PHONE p WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DAT PERMIT EXPIRATION DATE CHECK# PER MIT AMOUNT SURCHARGE AMT. >\ FEE CODE RECEIPT# BY: FORMB(37-m, THIS FORM MUST BE ACCOMPANIED BYAFACILITY/DATA PROCESS ORM'A',UNLESSAL flRENT FORM'A' HASBEENFILED