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C, xwoz � STATE OF CALIFORNIA-`, WATER RESOURCES CONTROL ` 9ARD FORM B': UNDEh ROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION „ COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - Z Lp MARK ONLY WNEW 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 1117 FACILITY/SITE NAME WHERE TANK IS INSTALLED: -b--T— FARM TANK-YES❑ NO J1, IV I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY ,A A. OWNERS TANK ID N W flC7t O— I B. MANUFACTURED BY: C. YEAR INSTALLED cl 81 1 D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.11),IS MARKED,COMPLETE ITEM C.IF(A.T),IS NOT MAR D,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM e. 1 UNLEAD ❑2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT GA OL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY ❑95 UNI WAS ❑7 HANDL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.N. C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITE LIN 6A. tf\iD A. TYPE OS STEMF ❑ 95 UNKNO 1 OOUBLEkllW WALLED / ❑WALLED 0 SING ARI CONT fll IN ❑99 OTHERWN ❑ I EUIRO 2 STAINLESS STEELv95,,u;;h UBS ❑4STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 6 POLYVINYLCHLORIDE U ❑8 IW%METHANOLCOMPATIBLEFRP MATERIAL ❑9 BRON ❑ 1 VANIZED STEEL ❑99 OTHER C. INTERIOR 1 RUBBER LINED E] L NG ❑ Vi ❑4 PHENOLIC UNING LINING ❑ 5 GLASS LINING 6 U INED ❑ 95 UNKNOWN ❑ IS LINING MANP110;+A 100%METH OL? ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POL EW 2 TARO SPHALT 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CA CTI ❑91 NE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE FABOV GR U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 P SSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE W ED U OUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/14614 A STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALU NUM fi CONCRETE A U 7 STEEL CLAD W/FRP A U S 100%METHANOL COMPATIBLE FRP A U 9 LVANIZED STEEL 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 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S I PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF3.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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# do S I oo CURRENT LOCAL AGENCY FACILITY IDN APP ED NAME I/ PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMITEXPIRATIONDATE CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE SAECEIPT N BY: FORM B(6-29-BB) THIS FORM MUST BE ACCOMI A FACILITY/SITE APPLICATION, FORM 'A',UNLESS At,(AFIENT FORMA' HAS BEEN FILED DATA PROCE,S,SING COPY