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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B'. UNDERGROUND STORAGE TANK PROGRAM u`* TANK PERMIT APPLICATION INFORMATION TANK -� COMPLETE A SEPARATE FORM WITH THE FOLLOWING IN RMATION FOR EACH TANK. £17 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 2-5--'CHANGE 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; LU-y1 FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY d A. OWNERS TANK ID# -IV 1 8, MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: (-I cza II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL `4 ©'�3 CHEMICAL PRODUCT F-] 4 OIL PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOLHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF 1(433:3--) HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.0: I x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B, ,A D A.TYPE OF ❑ 1DO LE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGLASSREINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOLCOMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWNTHER P7 KIP _ C. INTERIOR F-11 RUBBER LINED ❑ 2 AL INING ❑ 3 EPDXY LINING E] 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING LLtfUNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑ASPHALT ❑ 3 VINYL WRAP L]4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHOOICPROTECTION NONE ❑ 95 UNKNOWN ❑'99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGHOUND,BOTH IF APPLICABLE A. SYSTEM TYPE A SUGLON A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W1 TRIP 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 I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS W P S 6 PRECISION 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(M /YR) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH /L SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑ YES ❑ NO /\f THIS FORM HAS BEEN OMPLETED 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# JURISDICTION# AGENCY# FACILITY ID# TANK ID# [E�l I I I I I I I I I oa 9 191 1 o I I CURRENT LOC L ENCY FACI PTY s�ID# ,` APPROVED BY NAME PHONE#WITH AREA CODE f PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE JREEIPT# BY: FORMB(3-7-B6) THIS FORM MUST BE ACCOMPANI O A FACILITY/SITE APPLICATION, FORM `A',UNLESSRENT FORMA" HAS BEEN FILED DATA PROCESSING COPY