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STATE OF CALIFORNI R WATER RESOURCES CONTRY BOARD FORM 'B': UNDgKGROUND STORAGE TANK PROGRAM TANK &` TANK PERMIT APPLICATION INFORMATION ou COMPLETE A SEPARATE FORM WITH THE FOLLOWINGRWbRMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWALPERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDT ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED /� C FACILITY/SITE NAME WHERE TANK IS INSTALLED: �Q ��y- �/Lr�® FARM TANK•YES 0 NO � I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID p B. MANUFACTURED BY: 64< C C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: D II. TANK C TENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM O. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. 1 UNLEADED ❑ 2 LEADED E] 3 DIESEL B. ❑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 HAZARDOUS SUBSTANCE STORED&CAS.N C.A.S.p: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ t P061LE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 WAINUM ❑8(GOY.METHANOL COMPATIBLE FRP MATERIAL ❑9 BRON7E ❑ 10 GPIVAN12E0 STEEL YJ'9�SUNKNOWN ❑ 99 OTHER ❑ I RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXY UNING ❑ 4 P CUNING C. INTERIOR LINING ❑5 GLASS LINING ❑6 UNLINED 95 U NOWN ❑ IS LINING MATER14 COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO OTHER D.CORROSION ❑ I POLYETNENE WRAP ❑2 TAR OR ASPHALT ❑3 V LWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION [—] 5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 9t NONE A U 95 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 A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 6 100%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 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 3 6 PRECISION TESTING P 6 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 UST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK IO N = = = O ZI/ CURRENT LOCAL AGENCY FACILITY ID I APPROVED BY NAME PHONE 1 WITH AREA COD! PERMIT NUMBER PERMIT!ROVAL DATE PERMIT EXPIRATION DATE O CHECK p PERYIT AYOUNT SURCHARGE AYT. FEE CODE RECEIPT 0 BY: Gv� FORM B 19-29-fie) THIS FORM MUST BE ACCOMPANIED P A FACILITYYSITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED / DATA PROCESSING COPY