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STATE OF CALIFOFMIA WATER RESOURCES CONTROL 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 ❑ I NEW PERMIT ❑ S RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 1 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/BITE NAME WHERE TANK IS INSTALLED: b( S , rj7 Ci Y. FARM TANK-YES❑ NO f r r I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY ' A. OWNERS TANK ID S G B. MANUFACTURED BY: �K C. YEAR INSTALLED UK D. TANK CAPACITY IN GALLONS: Srjo D' 11. TANK CONTENTS IF(A.I).IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A. Ef I 1 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C L] I UNLEADED ❑ 2 LEADED DIESEL F-1S CHEMICAL PRODUCT ❑A OIL 1 PRODUCT ❑ 1 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BO 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 A CA.S.R C.A.S.N: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK AB,C.AD A TYPE OF ❑ IIDOUBLE WALLED ❑ 7 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑'2 SINGLE WALLED ❑ 1 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRON ❑ 2 STAINLESS STEEL ❑ 0 FIBERGLASS ❑/SHELUMW/RBERGUSSBEINFORCEDRMTIC B MATERIAL ❑5 CONCRETE ❑8 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 T00%METHANOL COMPATIBLE fHP ❑ 9 BRONZE ❑ 10 GALVM12ED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RIBBERLINED ❑ 2P-M LINING ❑ 0 EPDXY LINING ❑ 1 PHENDUCUNING LINING ❑ 5 GLASS UNING 0 B UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH TO^METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYUHLENE WRAP ❑2 TAR OR ASPHALT ❑0 WNYLWRAP ❑ T FIBERGLASS ACINFORCEDPIASTIC PROTECTION ❑ 5 CAMOOIC PROTECTION Cl 91 NONE D-0-614KNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE: A U B GRAVITY A U 91 NONE A 'LL 95 LNKNO -N A U 99 OTHER B. CONSTRUCTION _ 'l SINGLE WALLED A U 2 DOUBLE WALLED A U B LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 O1 HER <! A 1 a3TlEEL/�IRON A U 2 STAINLESS STEEL A U S POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 1009Y METHANOL COMPAI IBLE FRP A U 9 OALVAN17EDSIFEL A U 95 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. P S I VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 9 VADOSE W@LLS P S A ELECTRONICMONI/OR P S 5 GROUND WA1ER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTINO P S 9t NONE P 995 UNKNOWN p 0 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE UST USED(MO/YB) 2 ESIIMATEOOUANTIIYOF B. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLON B INERT MATERIAL? E]YES 0 N THIS FORM HAS BEEN COMPLETED UNDER PENALTY 017 PERJURY,AND TO THE REST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED A SIGNAIURE) DATE LOCAL AGENCY USE ONLY COUNTY I rJURISDICTION 0 (�AGNCCY# FACILITY ID 0 TANK ID e CURRENT LOCK AGENCY FACILITY ID/ A►PROYEG R1 NAME PHONE I WITH AREA COO[ b'?�ti7-� i PERMIT NUMBER PERMIT APPROVAL DATE PERYR EXPIRATION OAT[ CHECK F PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT A / sr: C� fORMBRI2986) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A'.UNLESS A CURRENT FORY'A' MAARcruolen