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STATE OF CALIFOR NI.A,,., WATER RESOURCES CONTROL%--�ARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION - COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT B-5-CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM F-12 INTERIM PERMIT 4 AMENDED PERMIT [:]6 TEMPORARY TANK CLOSURE 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 00 L FARM TANK-YES NO I. TANK DESCRIPTIONCOMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 A. OWNERS TANK ID q ,-J B. MANUFACTURED BY: C.YEAR INSTALLED IfIq 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. CEJ A. r-� 1 MOTOR VEHICLE FUEL r--j 2 PETROLEUM B. C. 1 UNLEADED E]2 LEADED r-]3 DIESEL ' 3 CHEMICAL PRODUCT EB--C-OILl PRODUCT 4 GASAHOL 5 JET FUEL r--j 6 AVIATION GAS E]5 HAZARDOUS 80 EMPTY [D 95 UNKNOWN 0 2 WASTE E] 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF p HAZARDOUS SUBSTANCE STORED&C.A.S.q r t7 bi6-Ic S'ttR DQ x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,&D O A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER F-1 95 UNKNOWN SYSTEM Q 2 SINGLEWALLED 4 SECONDARY CONTAINMENT 99 OTHER I STEEL/IRON 2 STAINLESS STEEL �3 FIBERGLASS �4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK r-�5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE El 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER C.INTERIOR 1 RUBBER LINED El2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING LINING ❑5 GLASS UNING E4-MINED 95 UNKNOWN IS UNING MATERIAL COMPATIBLE WITH 1 OD%METHANOL? YES ❑ NO 99 OTHER D.CORROSION ❑ I POLYETHL.ENE WRAP [:]2 TAR OR ASPHALT F-1 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION Ea'91NONE ID 95 UNKNOWN E]99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER fpv, STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C.MATERIAL 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. LLRECISION ISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 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 LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES F-1NO]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 N JURISDICTION A AGENCY# FACILITY ID 11 TANK ID# _-_ 1010 1 1 1 1 00 0 CURRENT LOCAL AO NCY FACILITY ID 71 APP VED BY N " E PHONE K WITH AREA CODE 0 PERMIT NUMBER f PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK r PERMIT AMOUNT S""CHARGE AMT. FEE CODE REQ-'PT M BY: FORM B(3-7-69) THIS FORM/BUST BE ACCOMPANIED-0Y A FACILITY/SITE APPLICATION, FORM `A`,UNLESS AI RRENT fORk1'A' HAS BEEN FILED J DATA PROCESSING COPY