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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD sf. FORM `B': UNDERGROUND STORAGE TANK PROGRAM ' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Y p MARK ONLY NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED Gi/ FACILITYISITE NAME WHERE TANK IS INSTALLED: /�. (,� FARM TANK-YES❑ NO (� l..i 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Q A. OWNERS TANK ID# `L B. MANUFACTURED BY: IV C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: �I, ll. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. VIVOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL �PRODUCT ❑ 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&CA S.# C.A.S.#: Ill, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ I D UBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM Lkff2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER �STEUIRON F-] 2 STAINLESS STEEL [-] 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-] 5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR F-] 1 RUBBER LINED E]2 ALKYD LINING ❑ 3 EPDXY LINING E:] 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING UNLINED ❑9 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 ff?5 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 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SfNGLE 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 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W1 FRP A U 6 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AU 5 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 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTINGP S 7 PRESSURE TESTI NG P S 91 NONE P S 95 UNKNOWN P S 99 OTHER j VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMAT D DATE LAST USED{MO/YR) 2. ESTIMATED OUA OF 3. WAS TAN ILLED WITH SUBSTANC RE ITV ❑ NOGALONS INEYES THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PE If AND TO THE BEST OF MY KNOWLED E IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# d 1 Q 16 1 6 1�:]' CURRENT LOCAL A"ENCY IF ILITY ID N APPROVED NAME• L u PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PE IT EXPIRATION DATE -7 CHECK k PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT 9 BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMP ED BY A FACILITY/SITE APPLICATION, FORM 'A',I IN'Fgn CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY