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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': l>o,DERGROUND STORAGE TANK,,,,,iOGRAM TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 P ANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSUREol TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES F] NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID p B. MANUFACTURED BY: �. C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 2�a s� � II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. --A--El MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED 2 LEADED ❑ 3 DIESEL `r ❑3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF / C.A.S.p: ; .r HAZARDOUS SUBSTANCE STORED&C.A.S.p Q ,y III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D .., A.TYPE OF ❑ E WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEUIRON ❑2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK �- F-1 5 CONCRETE ❑8 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑8 10091 METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE E] 10 GALVANIZED STEEL ❑95 UNKNOWN E]99 OTHER I RUBBER LINED ❑ 2 LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING `--' C.INTERIOR ❑5 GLASS LINING 6 UNLINED ❑95 LINK LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO OTHER I POLYEfHLENE WRAP AR OR ASPHALT F]3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC D.CORROSION ❑ ' PROTECTION ❑5 CATHODIC PROTECTION z 91 NONE ❑95 UNKNOWN ❑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 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1.STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A�ALUMINUM A U 6 CONCRETE A U 7 ST A EEL CLADW/FRP A U 8 100%METHANOLCOMPATIBLEFRP 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. �-• )t P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE .....r 1.ESTIMATED DAT LAST USED(MO/YR) 2.ESTIMAT D QUANTITY OF 3.W TANK FILLED WITH / SUBS REMAINING IN MATERIAL? ❑YES ❑ NO GALLONS THIS,FORM HAS BEEN COMPLETED UNDER PENAL OF PERJURY,AND TO THE BEST OF MY KN SEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) - DATE LOCAL AGENCY USE ONLY ' COUNTY/ JURISDICTION M AGENCY M FACILITY ID N TANK ID* v L t? � 3 CUR NT LOCAL AGENCY FACILITY ID 0 APPR VEgCBB Nr; r PHONE N WITH AREA CODE .T. ELL}.-rte ``// (/g_ G %! PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT 11 BY: a ' FORM a I6-29-86) THIS FORM MUST BE ACCOMPANIED e1 A FACILITY/SITE APPLICATION, FORM'A',UNLESS A t;UARENT FORMA' HAS BEEN FILED r DATA PROCESSING COPY