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i STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANKTANK PERMIT APPLICATION INFORMATION TANK. Z COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH O MARK ONLY ❑ I NEWPERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 6�0 TANK REMOVED N �� ,`, FARM TANK-YES❑ NO W FACILITY/SITE NAME WHERE TANK IS IN 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY (( ', 1 B. Q•-F " A. OWNERS TANK IDA 3 6 M� BMANUFACTURED BY: tk � C. YEAR INSTALLED 227 D. TANK CAPACITY IN GALLONS: Z. CIO(, 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. [0 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C.® 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.R: HAZARDOUS SUBSTANCE STORED&C.A.S.P III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A. TYPE OF ❑�I DOUBLE WALLED � 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM I�SINGLE WALIID ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER kg1 STEEL./IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLADWIFIBERGIASS REINFORCED PLASTIC - B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8188%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ i RUBBER UNED F-12 AUKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOfl5 GLASS UNING �6 UNLINED ❑95 UNKNOWN LINING ❑ ❑ISUNING MATERIAL COMPATIBLE WITH IW%METHANOL? YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP C72 TAP OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECION ❑91 NONE ❑ ❑ 95 UNKNOWN 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE 11 A. SYSTEM TYPE U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U 91 NONE 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL 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 1 VISUAL CHECK P 3 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 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(MO/VR) 2.ESTIMATED QUANTITY OF eD WITH SUBSTANCE REMAINING IN L. ❑YESj[:] NOGALLONSTHIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KTRUE AND CORAPPLICANT'S NAME(PRINTED 8 SIGNATURE)LOCAL AGENCY USE ONLYCOUNTYN JURISDICTION R AO NCYS FACILITY ID NTANK ID ND =CURRENT LOCAL AGENCY FACILITY ID• APPROVED Y NA E NE N WITH AREA CO V1112-PE ITNUMBER PERMIT APPRO TE PERMITEIPIRATION DAN CHECK# PERMITAMOV SURCHARGE ANT. FEE CODE RECBY: FORM B(6-2986) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITEAPPUCATION, FORM `A',ONLESS A CURRENT FORMA' HAS BEEN FILED n ATA PROCERRING COPY