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I ' STATE OF CALIFORNI/I WATER RESOURCES CONTRO ARD FORM `B': UNDERGROUND STORAGE TANK PRO AM TANK PERMIT APPLICATION INFORMATIONS TANKCOMPLETE 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 ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED. LLolloIdes-1,4n FARM TANK-YES❑ NO W 1, TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFYcr) ��// A. OWNERS TANK ID# - B. MANUFACTURED BY: .AL C. YEAR INSTALLED 6 D. TANK CAPACITY IN GALLONS. II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. I vl ' MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BD 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&CA.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM �SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER STEEL/IRON 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE El6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑ 8 106%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVAN17EDSTEEL ❑ 95 UNKNOWN ❑ 99 OTHER F-] 1 RUBBER LINED ❑ 2 ALKYD LINING F-] 3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR 5 GLASS LINING 6 UNLINED 95 UNKNOWN LINING ❑ ❑ ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP [012TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS 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 T SUCTION A U 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 U 95 NKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDF(PWC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A /U�8 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 6 195 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. P1 VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING 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 LOST USED(MO/YR) 2.�SUBSTAN�OEREMAIN�INGIN ESTIMATED 3- WAS TANK FILLED WITH „ INERT MATERIAL? ❑ YES ❑ NO 'rfr �� 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 COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# = I I Lj 1 n I ol / 6 � 1l � FRENT LO L AGENCY FACILITY ID# APPROVEEJD BY AME PHONE#WITH AREA CODE /q C 1 , a(�{.'�T PERMIT NUMBER PERMIT APPROVAL DiTd PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: L I FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANI A FACIUTYlSITE APPLICATION, FORM 'A',UNLESS A - RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY