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"`-r'�.A:T...+r�^^w..w+!�^-�,.�"�'4^�i.,?^T..�.TAT-,+'..��^..nw�.�Sw.gJ�(7+�+..was' ��p..+.� ...•w-meq......... �, STATE OF CALIFORI# WATER RESOURCES CONT BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWINFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C 0;: ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE �/�❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: ?3 3 /e 6e --}}�ileP -}e 41fFARM/TANK-YESIf ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY WCL -14M4 LL� �'uOPt �I A. OWNERS TANK IDN + B. MANUFACTURED BY: 7 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 00 0 11. TA CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM8. C E] 1 UNLEADED D?r2 LEADED ❑3 DIE; F-13 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL 6 AVI, 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM I D IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.# C.A.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,B D A. TYPE OF 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER E]95 UNKNOWN SYSTEM 7717��2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER IJ 1 STEEUIRON ❑ 2 STAINLESS STEEL FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE 7 ALUMINUM ❑6100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 59 OTHER ❑ C. INTERIOR I RUBBER UNED ❑2 AUKYD LINING ❑3 EPDXY LINING ❑ HENOLIC LINING LINING ❑ 5 GLASSLINING ❑6 UNLINED 9 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IDD%METHANOL? E]YES E]YES OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑ 2 TARORASPHALTVIWLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION [:] 91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFAS EGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION U PRESSURE A U 3 GRAVITY A U 91 NONE A 95 UNKNOWN A U B. CONSTRUCTION A U 1 SINGLE WALLED A 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE U 5 UNKNOWN A U A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 9 C. MATERIAL A U 5 ALUMINUM Ajp 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE A U 9 GALVANIZED STEEL A U>5 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE C S 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSEWELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITOT P S o 6 PRECISION TESTING S 7 PRESSURETESTING 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? E]YES THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND COR APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY 10 OCM 0&,J TANKID# = 1 �Lf G' v 0 CURRENT LOCAL AGENCY F4ICILITY ID# 3 3 APPROVED BY NAME PHONE#WITH AREA COI PERMIT NUMBER WW Pr PERMIT APPROVAL DATE PERMIT EXPIRATION DATE Jz/7- s' CHECK# PERMITAMOUNT �RCHARGE AMT. FEE CODE tIPT# BY: FORM B(6-29-88) THIS FORM MUST BE R.000MPANI 'AFACILITY/SITE APPLICATION, FORM 'A',UNLESS A uuRRENT FORMA' HASBEENFILED