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STATE OF CALIFORN' `, WATER RESOURCES CONTF BOARD FORM B': UNDERGROUND STORAGE TANK PROGRAM Y: TANK TANK PERMIT APPLICATION INFORMATION , �` COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1 NEWPERMIT 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 21NTERIMPERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE D TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY -7rZ4j& 10 A. OWNERS TANK ID# V K B. MANUFACTURED BY: YK C. YEAR INSTALLED / C D. TANK CAPACITY IN GALLONS: S IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. 00 A. ❑ 1 MOTOR VEHICLE FUELIIT��T�(��, PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL ❑ MICAL 3 CHEPRODl1CT IJ `OIL ❑ 1 ODUCT ❑4 GASAHOL ❑5 FUEL ❑6 AVIATIONGAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN M 2 WASTE ❑7 METHANOL 99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# W QG�k 0 -,/ C.A.S.#: .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,A D A TYPE OF ❑ DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 0 9 UNKNOWN SYSTEM M LE WALLED ❑4 SECONDARYCONTAINMENT 0 9 OTHER 1 STEEUIRON F-]2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM 6100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING 3 EPDXY LINING ❑4 ENOUC LINING LINING F-15 GLASS UNING ❑6 UNLINED 95 UNKNOWN ❑ SLIMING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES NO 0 9 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAAORASPHALT ❑ NYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNOERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A 3 GRAVITY A 99 U OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 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 PE C. MATERIAL A U 5 ALUMINUM A IF)6 CONCRETE A U 7 STEELCLAD W/FRP A U 8.190%METHANOL,COMPATIBLE FRP A U 9 GALVANIZED STEEL A U U 95 UNKNOWN A U 99 OTHER ,,LLV. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A-PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. /1 S I VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS 6 Ill P 5 8 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? DYES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. F777 NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# '�J\ I L) z � 10 100 111 CURRENT LOCAL AGENCY FACILITY ID* APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE TERMITEXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE I RECEIPT# BY: FORM B(3-zee) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED S DATA PROCESSING COPY