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STATE OF CALIFOU 1 WATER RESOURCES CONTF '. BOARD FORM 'B': UNDERGROUND STORAGE TANK PR-OGRAM ;mai TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INF RMATION FOR EACH TANK. - Z 7 O MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWALPERMIT 2<CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 0 FACILITY/SITE NAME WHERE TANK IS INSTALLED: j .SQ op /Lf , Z)vi-c p FARM TANK-YES❑ NO N CD I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY (V A. OWNERS TANK ID# yy p w _o B. MANUFACTURED BY: ale- N C. YEAR INSTALLED 3 D. TANK CAPACITY IN GALLONS: adQ (� II. TANKPONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,,o6MPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICALPRODUCT F-] B.4 OIL 1 PRODUCT ❑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 S C.A.S.# 1L C.A.S.#: a(( III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A. TYPE OF ❑ 1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 O7H F-11 STEEL/IRON ❑2 STAINLESS STEEL V F-14 S 3 FIBERGLASS TEEL CLAD W/FIBERGLASS REINFORCED PLASTIC S. TANK ❑ MATERIAL 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 'MB METHANOL COMPATIRI PERP ❑ 9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑W OTHER _ C. INTERIOR F--] 1 RUBBER UNED ❑2 ALKYD LINING E]3 EPDXY LINING ❑4 P OLIC LINING LINING ❑ 5 GLASS LINING F-16 UNUNED � 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IDA METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑? POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP EeITII 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 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 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 95 UNKNO A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM 600NCRETE A U 7STEELCLADW/FRP A U 8ll0 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEWA U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK D ECMOSYST M UST BE IR LE P 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR:1'3-5 5 GROUND WATER ONITORING WELLS P S 6 PRECISION TESTING P S 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 INERT MATERIAL? ❑YES ❑ NO GALLONS I 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 i LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# /CURRm I I I I I I I O I U I U I::/]- CURRENT ENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKN PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# FORM B(1-29-11) THIS FORM MUST BE ACCOMPANIE,,IA FACIUTY/SITEAPPLICATION, FORM 'A',UNLESS AIDW.RENT FORMA' HAS SEEN FILED ! / DATA PROCESSING COPY "