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STATE OF CALIFORN' � WATER RESOURCES CONTF BOARD FORM `B': LIND&GROUND STORAGE NK PROGRAM TANK PERMITA APPLICATIONINFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. s Z to MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE K ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE W FACILITY/SITE NAME WHERE TANK IS INSTALLED: Q.7- /` /l�( ?2 FARM TANK-YES❑ NO (,V I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 0 A. OWNERS TANK IDN B. MANUFACTURED BY: co C. YEAR INSTALLED Vx D. TANK CAPACITY IN GALLONS: Z1 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 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADEDE?Tf-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 HAZARDOUS SUBSTANCE STORED&C.A.S.N C.A.S.N: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.IS D A TYPE OF ❑ I OOIMLF.WALLED ❑3 SINGLE WAILED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ffKSINGLE WAILED ❑4 SECONDARY CONTAINMENT ❑99 OTHER [--] 1 STEEUIIDN ❑2 STAINLESS STEEL 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK YMATERIALF-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ T NAINUM EZ 8 100%MEIHANOLCGMPATIBLEFRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C.INTERIOR F-1I RUBBER UNE) ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING � LINING ❑5 GLASS UNING E]8 UNLINED D4 UNKNOWN ❑B LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO Q40THER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE #KNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE / A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER (///V B.CONSTRUCYION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I STEELARON 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 7STEEL CLADW/FRP A U 8I0 METHANOLOOMPATIBLEFRP 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 8 1 VISUAL CHECK P 8 2 INVENTORY flECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS I"11f P 8 8 PRECISION TESTING P S 7 PRESSURE TESTI NO P 8 91 NONE P S 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OFOALLONB 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION# AGENCY# FACILITY ID N TANK ID# = I oo � ylsy I 101 '-� oz CURRENT LOCAL AGENCY FACILITY IDAPPROVED BY NAME PHONE X WITH AREA CODE C Nv PERMIT NUMBER PERMIT APPROVAL DAI-E PERMIT EXPIRATION DATE ^��p CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT♦ BY: FORM B(6-29-BB) THIS FORM MUST BE ACCOMP . BYA FACILRY/SITE APPLICATON, FORM`A',UNLESS A URRENT FORMA' NAS BEEN FILED DATA PROCESSING COPY