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STATE OF CALIFORN& WATER RESOURCESCONTR&OARD FORM 'B': UNDERGROUND STORAGE TANK PR RAM TANK v TANK PERMIT,APPLICATION INFORMATION ® COMPLETE A SEPARATE FORM WITH THE FOLLOWING 1 NATION FOR EACH TANK. , MARK ONLY ❑ I NEW PERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED O9 FACILITY/SITE NAME WHERE TANK IS INSTALLED: 35,� Q#) FARM TANK-YES O I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK IDq R. MANUFACTURED BY: GlIG C. YEAR INSTALLED uk D. TANK CAPACITY IN GALLONS: 3-5-0 O Q II. TANK CO NTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. CO A. MO TOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED IESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL I 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&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D I WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN A TYPE OF ❑ SYSTEM 2 SINGLE WALLED —]4 SECONDARY CONTAINMENT 99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TMATERIALANK F-1 5 CONCRETE ❑6 POLYVINYLCHLORIDE 519 7 UM &iW%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED MEL5 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBERUNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 P CLINING LINING F—]5 GLASS LINING F--] 6 UNUNED 95 UNKNOWN ❑ IS LINING MATERMLCOMPATIBLE WITH 1DO%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TARORASPHALT ❑3 VI P ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, 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 A U S U 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 C 95 UNKNOWN > U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSESTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE � C. MATERIAL A U 5 ALUMINUM A GUNKNONCBEZ A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 95 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 8 1VISUALCHECK P S 2INVENTORY RECONCILIATION P S 3VADOSE WELLS P 8 4 NIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURETESTING P 8 91 NONE P 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY WON ait COUNTY# JURISDICTION# AGENCY# FACILITYI # TANK ID# FT71 `f Oho / CURB LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKM PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: C 1 FORM B(6-29-6a) THIS FORM MUST BE ACCOMPANIED BY A .. ITYISITE APPLICATION, FORM 'A',UNLESS A CURRENRIFORM W HAS BEEN FILED \i DATA PROCESSING COPY