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STATE OF CALIFORNIAWATER RESOURCES CONTROL ARD FORM 'B': UNDERG_ROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INQO FORMATION FOR EACH TANK. z MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT I O 'SCHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED ��7/ b5 FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3 O F r ,Q/ FARM TANK•YES NO ❑ CA) N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY GC 6e� � � ~ A. OWNERSTANKID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS' 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 ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ q OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BO EMPTY UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME O HAZARDOUS SUBSTANCE STORED&C.A.S.# CAS #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.S D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLEWALIED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 IDA METHANOL COMPATIBLEFRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL LW95 UNKNOWN ❑ 99 OTHER ❑ C.INTERIOR 1 RUBBER LINED ❑2 ALKYD LINING E] 3 EPDXY LINING ❑4 ENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLEWITH 10D%METHANOL? YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 INYL WRAP ❑4 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 tU 5 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 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 Ao CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE 8 5 UNKNOWN P B 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 E] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# MI = = 10 O a0o CURRENT LOCAL AGENCY FAGIL APPROVED BY NAME PHONE#WITN AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMITEXPIRATIOM DATE 6�3 8 CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODERECEIPT# BY: �� FORM B(6-29-w) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' NAS BEEN FILED DATA PROCESSING COPY