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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION o COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑7 RMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSSU+RREp _?,FARM S TANK REMOVED`7 FACILITY/SITE NAME WHERE TANK IS INSTALLED: ZS S S 1 /N //ARM TANK.YES❑ NO El Z I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY 10 A. OWNERS TANK IDR B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: SQ W 11. TAlIlK,60NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM 0 A [IPI I MOTOR❑ 3 CHEM CAL VEHICLE FUELRODUCT ❑4 PETROLEUM B 1 PRODUCT C ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL ❑ 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 8 C.A.S.R C.A.S.W All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A. TYPE OF ❑ UBLE WALLED F—] 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 1�2INGLEWAUED ❑4 SECONDARYCOMAINMEM ❑99 OTHER 19", STEBUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%MErHANOLOOMPATIBLEFRP MATERIAL ❑9 BRONZE ❑ 19 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING 4 P}IENOLIC LINING C. INTERIOR IL��/ LINING ❑5 GLASSLININ6 UNLINED 95 UNKNOWN G ❑ ❑ IS LINING MATERIAL COMPATIBLE WITH 1M%METHANOL? ❑YES NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHIENEWRAP ❑2 TAR OR ASPHALTINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION E]91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE fm A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSUREA U 3 GRAVITY A-U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A 3 LINED TRENCH U_)95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%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. O/J P 3 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS I8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 95 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,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY X JURISDICTION k AGENCY R FACILITY ID R TANK ID k CURRENT LOCAL AGENCY FACILITY ID k APPROVED BYNAME PHONE X WITH AREA CODE GL�},e�-i Z . PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE \IU11 CHECKM PERMIT AMOUNT RCHARGE AMT. FEE CODE RECEIPT ... FORM B(3-7-Be) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPUCATION, FOJIM 'A',UNLESS A C ENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY