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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION � COMPLETE A SEPARATE FORM WITH THE FOLLOWING I RMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWALPERMIT 215 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑1 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: SS lye,c FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ION _ B. MANUFACTURED BY: C.YEAR INSTALLED o D. TANK CAPACITY IN GALLONS: II. TANK qdNTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),13 NOT MARKED,COMPLETE ITEM D. A. gi MOTOR VEHICLE NEL ❑2 PETROLEUM R. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑1 OIL - 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 60 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF �� So HAZARDOUS SUBSTANCE STORED 6 C.A.S.N C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF ❑ 1 WALLED 3 SINGLE WALLED WITH EIRERK)R LINER ❑ 95 UIMNJIYN SYSTEM DfSINGI.E WALLED ❑A SECONDARY CONTAINMENT ❑ 99 OTHER ❑ I STEELIIRON ❑2 STAIFRESSSTER F-13 FIBERGLASS F-1/STEEL GAD WIFIBERGIASS REINFORCED PLASTIC B.TANK MATERIAL ❑5 WNtl✓ETE LYW ❑6 PONfLCHLOROE ❑ 7 ALuMINuu ❑6 160%MEMANOLCOWATIBLERRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWNOTHER F41 f' ❑ C. INTERIOR 1 RUBBER LINED ❑2_A.KYD LINING ❑3 EPDXY LINING E)A PHENOLIC LINING LINING ❑ 5 GIMUNNG 6 UNLINED ❑ 95 UNKNO M ❑ ISUNING MATERIAL COMPATIBLE WITH 100%MEIM00400 ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I PoLYETHLLNE WRAP ❑2 T OR ASPHALT ❑3 VINYL VIIUP ❑ 1 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CA11NlGC PROTECTIONI L4 91 ONE ❑95 UNKNOWN 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION U,1 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 I STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U I FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B I ODW METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR 8 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. N IVISUAL CHECK P S 2 INVENTORY RECONCILIATION P 6 3VADOSE WELLS P N 1 ELECTRONIC MONITOR P N 5 GROUND WATER MONITORING WELLS 'p_$. B PRECISION TESTING P 6 1 PRESSURE TESTING P N 91 NONE P 6 95 UNKNOWN P 5 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 IVB/ 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. APPLICANTS NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION I AGENCY N FACILITY ID I TANK IO N r Q� � I o I o 7 1 � I yI I o I o I 0 .7 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKS PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT I BY: