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STATE OF'CALIFORI& WATER RESOURCES CONAL BOARD m;,• FORM 'B' UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION . COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. y`• u 1. 12 IMARK ONLY ,..,❑ I NEWPERMIT. ❑3 RENEWAL PERMIT 5 CIUNGE OF INFORMATION ❑7 PEflMANENTLY CLOSED TANK I C f- ONE ITEM ❑2INTERIM PERMIT ❑ 1 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED; - Z M 1t- GjA- FARM TANK-YES NO ❑ 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-60 SPECIFY A. OWNERS TANK 10 N B. MANUFACTURED BY: (L C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: It. TANK gO NTENTS IF(A.1),19 MARKED,COMPLETE ITEM C.IF(A 1),I NOT MARKED,COMPLETE ITEM D. A• 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ I UNLEADED LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ / OIL 1 PRODUCT ❑4 GASAHOL5 JET FUEL ❑ ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 CAS.p CAS.E: 111. TANK CONSTRUCTION MARKONE ITEM ONLYIN BOXA,B,C,LD k TYPE OF ' ❑rn I SBU WALLED E]3 SINGLE WALLED WITH EXTERIOR UNEfl 95 UNKNOWN SYSTEM LLJ 2 SINGLE WALLED ❑ /SECONDAWCONTAINMENT ❑ 99 OTHER B.TANK ❑ 1 STEEUIRON E] 2 STAINLESS STEEL ❑3 FIBERGLASS E] 1 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC 5 CONCPETE 6 POLYVINYLCRLORDE 7 u M MATERIAL '. ❑ ❑ L_L ❑6100%METHANOL COMPATIBLE FRP ❑9 BRONZE - [:j10 GALVANIZED STEELUNNNOVIN ❑99 OTHER C. INTEAIOR ❑ 1 RUBBERUNED ❑2 uKYO LINING ❑3 EPDX/UNING ❑ 1 CONING . LINING, ' ❑ 5 GLASSUNING ❑6 UNLINED N -❑ IS LINING LWTERULCOMPATIBLE WITH 100%METHNOL7 [:IVES NO 99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ NtL WRAP ❑/FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 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 91 NONE A U UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 5 UNKNOWN A U 99 OTHER A U I STEEUIRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U / RGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCIADW/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 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. P B 1 VISUAL CHECK P B 2 INVENTORY flECONCIUATION P B 3 VADOSE WELLS ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P B B PRECISION TESTING P B 7 PRESSURE TES71N0 P B 91 NONE P B Ot 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 ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,!S TRUE AND CORRECT. MPUCANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY Y ' -.JURISDICTION Y AGENCY E FACILITY ID M TANK 10 CURRENT LOCAL AGENCY FACILITY 10 E APPROVED BY NAME PHONE f WITH AREA CODE PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK/ PERMIT AMOUNT SURCHARGE AY T. fEE CODE ECEIPTI BY: ' ' ` FORM H IfiBO.NN, TRIC G(1Ru MI WT oc.rnn..e u ...... .