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STATE OF CALIFORNIt WATER RESOURCES CONTROI 'OARD °. FORM `B': UNDERGROUND STORAGE TANK PROGRP AM ' TANK TANK PERMIT APPLICATION INFORMATION m COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED oq FACILITY/SITE NAME WHERE TANK IS INSTALLED: lbrjr FARM TANK-YES❑ NO , 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# p`L -i-� B. MANUFACTURED BY: K C. YEAR INSTALLED L42 D. TANK CAPACITY IN GALLONS: W II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. Fes.' MOTOR VEHICLE FUEL ❑ 2 PETROLEUM IB. C. ❑ I UNLEADED jRr2 LEADED ❑3 DIESEL +� ❑3 CHEMICAL PRODUCT ❑ 4 OIL AKI I PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.If: .111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EOEAIOR LINER ❑95 UNKNOWN SYSTEM t2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 4J 1 STEELIIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 810D%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑W OTHER C.INTERIOR F-11 RUBBER UNE ❑ 2 ALKYD LINING ❑3 EPDXY UNING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING �ry I S UNLINED ❑95 UNKNOWN ❑ISUNING MATERIAL COMPATIBLE WITH IDD%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLFNEWRAP ;S TAR OR ASPHALT ❑3 VINYLWRAP ❑ 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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A Q 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER Aa 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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 5 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GR�JND WATER MONITORING WELLS P S S PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE ell 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/VR) 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 COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 6 1015- 318 , Q I U O Z CURRENT LOCAL AOENCV FACILIT-10# AO P Y NAME PHONE#WITH AREA CODE /oe PERMIT NUMBER PERMIT APPROVAL DATV PERMIT EXPIRATION DATE CHECK k PERMR AMOUNT SURCHARGE AMT. -FEE CODE RECEIPT# BY: FORM B(34.68) THIS FORM MUST BE ACCOMPANIE�'Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A=ARENT FORMA' HAS BEEN FILED