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STATE OF CALIFOROA WATER RESOURCES CONTI*BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM " TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑A AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 6 TANK REMOVED i 2_ FACILITY/SITE NAME WHERE TANK 18 INSTALLED: ClcmoIvt> FARM TANK-YES XLWO ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ON M Q B. MANUFACTURED BY: ,n C. YEAR INSTALLED n 0. TANK CAPACITY IN GALLONS C (,LjA 1 11. 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 ❑1 OIL Ix I 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 6 C A.S.N C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.S,C.8 D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTEROR LINER ❑%UNKNOWN SYSTEM 2 SINGLE WALED ❑A SECONDARY CONTAINMENT ❑99 OTHER I STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑A STEEL CUD WIFIBERGUSS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑B 108%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR 1 RUBBER LINED 2 ALKYDUNING E]3 EPDXY LINING ❑A PHENOLIC LINING LINING ❑5 GLASS LINING UNLINED ❑%UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOLP ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP �2 TAR OR ASPHALT ❑3 VINYL WRAP ❑/FIBERGLASS REINFORCED PLASTIC PROTECTION E] 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 =95 UNKNOWN A U 99 OTHER B. CONSTRUCTION //U)� 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER AFM{ I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE A U 91 NONE C. MATERIAL A VU 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 6 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A LA N OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P t 1 VS AL CHECK P B 2 INVENTORY RECONCILIATION P t 3 VADOSE WELLS P t A ELECTRONIC MONITOR P B 5 GROUND WATER MONITORING WELLS ► t 6 PRECISION TESTING P S 7 PRESSURE TESTING ► t 91 NONE ► S 95 UNKNOWN P B "OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATED DATE LAST USEO(MO/YR) 2. ESTIMATED OUANTITY OFGALLOMt 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN 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. APPL ,NTS NAME(PRINTED NA URE) / DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N (� TANK ID N T MI = = 1 1 (/ 7 CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAPE PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK• PERMIT AMOUNT SURCHARGE NIT. FEE CODE RECENT0 BY: i z6 ro pi FORM B 1839-BB) THIS FORM MUST BE ACCOVW A FACILMMU MIRMTKIM, FORM'A',UNLESS A FOBM'A' RMB BEEN FILED DATA . L OCESSING COPY $ LOCAL AGENCY:PILE COPY