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STATE OF CALIFORNIA WATER RESOURCES CONTROL `ARD FORM 'B': UNDERGROUND STORAGE TANK PROGKAM .,.. 4 TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INF ATION FOR EACH TANK- MARK ONLY 1 NEW PERMIT F—] 3 RENEWAL PERMIT CHANGEOF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED of FACILITY/SITE NAME WHERE TANK IS INSTALLED: //,"A- FARM TANK-YES❑ NO ❑ lz I, TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I® A. OWNERS TANK ID# -y�jo2UB. MANUFACTURED BY: G YEAR INSTALLED _l D. TANK CAPACITY IN GALLONS' 2 W II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM O. - A ❑ 1 M TOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. ❑ I UNLEADED ❑2 LEADED ❑3 DIESEL CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑SO EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ffpeoTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF 1J��,,��Q� HAZARDOUS SUBSTANCE STORED&CAS.# �. XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a 0 A.TYPE OF ❑ I LE WALLED ❑ 3 SINGLE WALLED WITH EIOERIOR UNER ❑95 UNKNOWN SYSTEM BNGLEWAUPO ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 PoLWINYL CHLORIDE ❑ 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 PHENOLIC LINING LINING ❑5 GLASS UNINGNED ❑ 95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 PoLYETHLENE WRAP ❑2TAR OR ASPHALT ❑ 3VIWL P ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONENKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSISTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5ALUMINUM AfiCONCRETE A U (STEEL CLAD W/FRP A U 610096 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION UEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. ' P 8 1 VISUAL CHECK P INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 0 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S fi PRECISION TESTING P S T PRESSURE TESTING P 8 91 NONE- P S 95 UNKNOWN P 8 99 OTHER Vl. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH 6 / 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. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE � LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# E21 10z 1016101 / CURRENT LOCAL AGENCY FACILITY ID# / APPROVED M16 PHONE#WITH AREA CODE S PERMIT NUMBER PERM( APPROVAL ATF ERMIT E% RATIO DATE CHECK# PERMIT AMOUNT SURCHARQ9AMT. \v FEE CODE RECEIPT# BY: FORM B(3-7-Asa) THIS FORM MUST BE ACCOMPANIE"C(A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A ENT FORMA' HAS BEEN FILED DATA PROCESSING CG