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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSUREANK REMOVED 09 FACILITY/SITE NAME WHERE TANK IS INSTALLED: k111a 0 S FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I A, OWNERS TANK IDR -ACTURED BY: Y2 C. YEAR INSTALLED `L D. TANK CAPACITY IN GALLONS: 'goo 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. Q A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM BC, E] 1 UNLEADED ❑ 2 LEADED DIESEL ❑ 3 CHEMICAL PRODUCT ❑4 OIL �t PRODUCT F]4 GASAHOL ❑ 5 JET FUEL F] 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.R v/4 C.A.S.W N/f .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I WUBLEWALLFD ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM !SINGLE WAU-ED ❑ 4 SECONDARYCONTAINMENT ❑99 OTHER $TEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNED ❑2 A D LINING ❑3 EPDXY LINING ❑4 PHENOUC LINING C. INTERIOR LINING ❑ 5 GLASS UNING UNUNED ❑ 95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE MTH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑ZT ROR ASPHALT ❑ 3 VINYL 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 0 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U MOTHER B. CONSTRUCTION AU 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER A©U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U S CONCRETE A U 7 STEELCLADW/FRP A U 810D%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. I� P S 1 VISUAL CHECK � 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS ot-%F' P PRECISION TESTING P S 7 PRESSURETESTING goS 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH WLLONS SUBSTANCE REMAINING IN INERT MATERIAL? YES E:]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 R JURISDICTION R AGENCY R FACILITY ID N TANK ID* 3� I DD I / 1 53o C} bD CURRENT LOCAL AGENCY FAN APPROVED BY NAMEd jo PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL OA PERMIT EXPIRATION DATE IT YJ4 CHECK* PERMITAMOUNT SURCHARGEAMT. FEE CODE RECEIPT* BY: \v1l FORM B(3-7-BB) THIS FORM MUST BE ACCOWMIE BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A pRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY' ,