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STATE OF CALIFORNI WATER RESOURCES CONTRL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION % ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING RYFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMI7 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED '- FACILITY/SITE NAME WHERE TANK IS INSTALLED: T TOO v✓- 15FARM TANK-YES❑ NO FLI--� . TANKOESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 96376 A_ OWNERS TANK ID p B. MANUFACTURED BY A C. YEAR INSTALLED LIL D. TANK CAPACITY IN GALLONS. Q I. TANK CONTENTS IF(A.1), ARKED,COMPLETE ITEM C.IF(At),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUELPETROLEUM B. / C. ❑ I UNLEADED ❑ 2 LEADED ❑3 DIESEL F73 CHEMICAL PRODUCT 4 OILPRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY [:] 95 UNKNOWN 2 WASTE ❑ T METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM C.BELOW) •- D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C A.S.N W� D / C.A.S.p' II. TANK CONSTRUCTION MARKONEITEMONLYINBO%A,B,C,AD A TYPE OF ❑ 10CW51WALLED ❑ 3 SINGLE WALLED WITH EXTEROR LINER ❑95 UNKNOWN SYSTEM SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER I ST IRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC ` B.TANK CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 6 LOG%METHANOL COMPATIBLE FAP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ C.INTERIOR RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPO%1'LINING /P UC LINING LINING ❑ S GLASS LINING ❑ 6 UNUNEO UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WTTHIOMMERIANOL2 ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TARORASPHALT ❑ J W P r-14 FIBERGLASS REINFORCED PLASTIC PROTECTION E] 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER Y. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A LA I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U UNKNOWN A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE AlU/55 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIOE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U./115 UNKNOWN A U 99 OTHER ,/. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR 5 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I WSUALCHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P LECTRONIC MONITOR P S S GROUNDWATER MONITORING WELLS P S B PRECISION TESTING P S 7 PRESSURE TESTING P 3 91 NONE UNKNOWN P S 99 OTHER INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE t. ESTIMATED DATE LAST USED(MO/YR) 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 EEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID 0 TANK ID N ELO1111 6 � o0 (f) CURRENT LOCAL AGENCY FACILITY IO Y_ G APPROVED BY NAME PHONE 4 WITH AREA CODE bvi t J I -�' PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 6-/y 8y CNECKI PERMITAMOUNT mJPCHANGE AMT.A_I FEE CODE T PTI BY: FORM B TB-29-Ki THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED