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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 4 FORM `B': UNDERGROUND STORAGE TANK PROGRAM 'S TANK TANK PERMIT APPLICATION INFORMATION ° COMPLETE A SEPARATE FORM WITH THE FOLLOWING I FORMATION FOR EACH TANK. „e; •� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANCE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: -I u �- FARM TANK-YES❑ NO ___I R--- I. TANK DESCRIPTION COMPLETE ALL ITEMS-1F UNKNOWN—SO SPECIFY A. OWNERS TANK ID# -7- 1-7 B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: ScoL II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A-1),IS NOT MARKED,COMPLETE ITEM D. I-A. A. ❑ 1 M TOR VEHICLE FUEL ❑ 2 PETROLEUM BC. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL CHEMICAL PRODUCT F—] 4 CPL - PRODUGT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ b AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF 14 3 3 3"J HAZARDOUS SUBSTANCE STORED&C.A.S.# UO C.A.S.W 1 31 013 2- xill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,&D A. TYPE OF ❑ 1 DOU WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER F—] 1 STEELPRON ❑2 STAINLESS STEEL F-] 3 FIBERGLASS ❑ 4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE F-16 POLYVINYLCHLORIDE F-] 7 ALUMINUM ❑ S 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN Ep-N OTHER r C. INTERIOR F-11 RUBBER LINED ❑ 2 AL LINING El3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑5 GLASS LINING UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAPVlTNONE R ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION E] 5 CATHODIC PROTECTION ❑ 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 99 OTHER B. CONSTRUCTION A& 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEELIIRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE 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 S T VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED GATE LAST U ED{MO/YR} 2. ESTIMATED QUANTITY OF 3. WAS TANK F,PLLED WITH ` I SUBSTANCE REMAINING IN INERT MATERIAL? ❑ YES F] NO /-' � GALLONS THIS FORM NAS BEEN COMPLET ED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SfGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# ED 1 1 11 EI I I I d ol t o 2 CURRENCAL AGENCY FACILITY ID APPROVED BY NAME PHONE#WITH AREA CODE ( PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT- T�ODE RECEIPT# BY: FORM B(3-7-88) THIS FORM MUST SE ACCOMPANI u AFACILITYISITE APPLICATION, FORM `A',UNLESS RENT FORM°A' HAS BEEN FILED DATA PROCESSING COPY