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STATE OF CALIFORtF. Q WATER RESOURCES CONT L BOARD - FORM 'B': UNMRGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING IN RMATION FOR EACH TANK. w� MARK ONLY ❑ 1 N PERMIT ❑3 RENEWAL PERMIT RANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REM FACILITY/SITE NAME WHERE TANK IS INSTALLED 330& N FARNITANK-11I NO ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY iO A. OWNERS TANK ID p B. MANUFACTURED C. YEAR INSTALLE U1,1I I D. TANK CAPACITY IN GALLON U II. TANK CO ENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. NLEADED ❑2 LEADED ❑3 DIESEL +` ❑3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS A ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE It ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF / HAZARDOUS SUBSTANCE STORED 8 C.A.S.N C.A.Sl (� All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTE �j ❑2 SINGLE WALLED ❑4 SECONDARY DONTAINMEM ❑99 OTHER l jo 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B'MATTER /S 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 ALUMI ❑8 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑3 EPDXY UNING o 4 PHENOL LINING LINING ❑ 5 GLASS LINING ❑6 UNUNED f NKNOWN �6 F-1ISLINING MATERIAL COMPATIBLE WITH 11 METHANO `� YES NO ❑99 OTHER D.CORROSIO 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTED ❑5 CATHODIC PROTECTION ❑91 NONE �KNDWN ❑ 99 OTHER IV. PIPING INFOR ATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTIO U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A I UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL 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 GALVANIZEDSTEEL A015 UNKNOWN A U 99 OTHER jv, Ill DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P IfIl PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE MATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH p4 SUBSTANCE REMAINING IN INERT MATERIAL? [::]YES [:] NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY 7 COUNTY# JURISDICTION# AGENCY# 4/ FACILITY ID# TANK ID If C NT LOCA OENCY�TY ID•, OVI E /� "/PHONE#WITH AREA CODE 9x /IIRMIT NUMBER 3l/// D PERMIT EXPIFIIOND Ojtj1� CHECK# PERMITAMOUNT SURCHA EAMT. f FEE CODE RECEIPT# BY: FORM B(3-7-BB) THIS FORM MUST BE ACCOMPANIED M A FACILITY/SITE APPLICATION, FORM 'A',UNLESSA ENT FORMA' HAS BEEN FILED I NG COPY