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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION (RZ COMPLETE A SEPARATE FORM WITH THE FOLLOWING INF RMATION FOR EACH TANK. 10 MARK ONLY ❑ 1 NEWPERMIT ❑3 RENEWALPERMIT 2-6-CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED '9 N FACILITY/SITE NAME WHERE TANK IS INSTALLED: S C>Ci FARM TANK-YES[—] NO W CD I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK IDN B. MANUFACTURED BY: C. YEAR INSTALLED I D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COAMILETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. 1 UNLEADED 2 LEADED 3 DIESEL F-13 CHEMICAL PRODUCT F-1 B.4 OIL i 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) 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.N C.A.S.q. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,&D A. TYPE OF ❑ ) DOUBLE WALLED ❑3 SINGLE WALLED WITH FXTERIOR UNER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLS) 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ i STEEL/IRON 2 STAINLESS STEEL 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC S. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE F-1 7 ALUMINUM 8100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE ❑10 GALVANIZED STEEL [:]95 UNKNOWN 99 OTHER C. INTERIOR ❑ 1 RUBBER UNED 2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOUC LINING LINING ❑5 GLASS UNING ❑6 UNUNED ❑95 UNKNOWN ISUNING MATEPoALCOMPATIBLEWITH I(B%METHANOL? YES ❑ NO 99 OTHER D. CORROSION ❑ 1 POLYEMIENEWRAP 2TAR OR ASPHALT 3VINYL 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 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 91 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 B CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOLCOMPATIBLEFRP 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. y P S I VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS 'll P S 6 PRECISION TESTING P 5 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 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 ONO i �NNV THIS FORM HAS EfEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY K JURISDICTION N AGENCY N FACILITY ID N TANK ID N = = 1016 1-1133 1 q I I Joy CURRENT LOCAL AGENCY FACILITY ID 9 APPROVED BY PIAME PHONE N WITH AREA CODE t PERMIT NUMBER PERMIT APPROVAL DATE MIT EXPI NDATE CHECK• PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT BY: \vY,/ FORM R(6-29-es) THIS FORM MUST BE ACCOMPANIErP A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A%1AREffr FORMA' HAS BEEN FILED -7CESSING COPY