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STATE OF CALIFOAW WATER RESOURCES COAL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK .TANK PERMIT APPLICATION INFO ATION COMPLETE A,SEPARATE FORM WITH THE FOLLOWING IN MATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑O RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑1 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: /'_('/_S_ S> FARMTANK-YES❑ NO I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK IDN 17/ B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: yOco J II. TANK CONTENTS IF(A.1),18 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A 1 MOTORVEHICLE FUEL ❑ 2 PETROLEUMB. 1 C. ❑ rNLEADED ❑ 2 LEADED E:]B DIESEL ❑ D CHEMICAL PRODUCT 4 OIL ✓' PRODUCT ❑ A GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 60 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 8 C.A.S.N - CA.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C.a D A TYPE OF ❑ 1 WALLU) ❑0 SINGLE WALLEO WITH EXTERIOR UNER ❑%UNKNOWN SYSTEM ff'2/SINGLE ❑ 1 SECONDARY CONTAINMENT 99 OTHER EEr' STEEUmON ❑2 STAINLESS STEEL ❑9 FIBERGLASS ❑/STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑B POLWINYLCHEoROE ❑ 7 ALUMINUM ❑ S 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE Ell 0 GAL4AMZED STEEL ❑ %UNKNOYIN ❑ 99 OTHER C INTERIOR ❑ I USER LINED [:] 2 ALM LINING ❑0 EPDXY UNING ❑/PHENOLIC LINING LINING ❑ 5 GUM LININGQ 8 UM1NE0 E] 95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METFWIOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYEIHUNEWAAP ❑2 TAA OR ASPHALT ❑0 YWL WRAP ❑A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ S ICATHOOICPROTECTION (241'NONE ❑%UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEYTYPE A U BDDTI A U 2 PRESSURE A U B GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER S.CONSTRUCTION A U I A U 2 DOUBLE WALLED A U 9 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A UffFIFFOCN A U 2 STAINLESSSTEEL A U 0 POLYVINYL CHLORIDE(PVC) A U AFIBERGLASSPIPE A U 91 NONE G MATERIAL A U S MMUM A U S CONCRETE A U 7 STEELCLADWIFBP 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 N 1 VISUAL CHECK P S 2 INVENTORY RECONCIUATION P N 9 VADOSE WELLS P B A ELECTRONIC MONITOR P B 5 GROUND W=MONIIORING P N. B PRECISION TESTING P B 7 PRESSURETESTING P N NORE'' P B 95 UNKNOWN P N 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE ^ 1. ESTIMATED DATE LAST USED(MOYYR) 2. ESTIMATED OUANTM OF 0.WAS TANK FILLED WITH 7 SUBSTANCE REMAINING INOAtIONB INERT MATERIAL? F]YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT �( APPUCANT'S NAME(PRINTED B SIGNAL URE) DATE LOCAL AGENCY USE ONLY r~ COUNTY E JURISDICTION N AGENCY N FACILITY ID N TANK IO N CURRENT LOCAL AOENCY FA:7 ID 1 APPROVED BY NAME PHONE#WITH AREA CODE L�T iVG S` fA PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DAT! J CHECK# PERMITAMOUNT BURCHARGEAMT. FEE COD! OR RECEIPT( BY: SWI ....,.....,.... TuIA cnoM uuet ec�rrnr.n�wcn er#urn mmx A '