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STATE OF CALIFORNIA WATER RESOURCES CONTR L BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM • TANK PERMIT APPLICATION INFORMATION . TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT F-17 RENEWAL PERMIT ❑'S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2INTERIM PERMIT ❑ T AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK 18 INSTALLED: ,_��.. �, ,n ,f _ FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY A. OWNERS TANK 10 1 : 1 B. MANUFACTURED BY: C. YEAR INSTALLED '/ O. 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- L 1 MOTOR VEHICLE FUEL F-12 PETROLEUM B. C. E] I UNLEADED 2 LEADED ❑ 7 DIESEL ❑0 CHEMICAL PRODUCT ❑ # OIL ❑1 PRODUCT ❑ T GASAHOL ❑ 5 JET FUEL ❑ 8 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 1 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 CA.S.I C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,L D A.TYPE OF ❑JDOUBUE WALLED ❑J SINGLE WALLED WITH EXTERIOR LNEA 95"Nb1M SYSTEM 2 SINGLE WALLED 6 SECONDARY CONTAINMENT ❑99 OTHER I STEEURON ❑2 STAINLESS STEEL ❑7 RBERGULSS ❑ 1 STEEL CLAD W/FIBERGLASS MINFCFaD PLASTIC B.TANK ❑5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 110D%MMMOLCOMPATIBUTW MATERIAL ❑ 9 BRONZE ❑ 10 GALVAM2EO STEEL E1.95 UwNm ❑ 99 OTHER C.INTERIOR ❑ I RUEIBEAUNED ❑j,MKYD LINING ❑ 7 EPDXY UNING A PHENOLICUNING LINING ❑5 GLASSUNING ❑8 lNA1NE0 ❑ 95 UMO90WM ❑ IS LINING MATERIAL COLWAT16LE WITH 100%METHANOL? ❑YES ❑NO 99 OTHER D.CORROSION ❑ I POIYETFEETIE WRAP ❑2 TAR OR ASPHALT ❑7 WNYI WRAP /FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION Er9I NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A u ClSUCTIO A U 2 PRESSURE A U O GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U I CSINOLE WALLS A U 2 DOUBLE WALLED A U 9 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U TEELAFlON ` A U 2 STAINLESS STEEL A U 7 POLYVINYL CHLORIDE(PVC) A U I FIBEROIASS PIPE A U 91 NONE C.MATERIAL A U S wTmmNUM A U 8 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 H0 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 E tjCILIATION P % ] VADOSE WELLS P % LELECTF1pNIC MONITOR P 6 SOROUNO WATER MONITORING WELLS 1 VISUAL CHECK P N Z:!MEiNTOFFV RE P N. ING P N 7 PRESSURETESTING P % 91 NONE P 9 95 UNKNOWN P { 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTDY OF1 WAS TANK FILLED WITH OALLON6 SUBSTANCE REMAINING IN INERT MATERIAL? YES ❑ ND THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY P JURISDICTION I �A"I(GENNCCYIj# FACILITY ID I TANK ID N = LTJ V7 U U O j CURRENT LOCAL AOENCY FACILITY 101 APPROVED AT NAME PHONE I WITH AREA CODE PERMITNUMEER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMITAMOUNT NURCHARGEAMT. FEE CODE RECEIPTI NT: