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STATE OF CALIFORNI, WATER RESOURCES CONTRI BOARD FORM 'B' UNDERGROUND STORAGE TANK PROGRAM _ TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACHTANK. z ' 'I•• MARK ONLY , •I PERMIT . ❑ D RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO41ANKONE ITEM L , INTEWM PFAMIT 1 AMENDED PERMIT ❑ 6 TEMF'ORAITY TANK CLOSURE ❑8 TANK REMOVEFACILITY/SITE NAME WHERE TANK IS INSTALLED: 1PS g , (G FARM TANK-YES❑ N 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY `7� Z0 (n A OWNERS TANK ID N B. MANUFACTURED BY: C. YEAR INSTALLED JG b' D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(Ary,IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A ❑ 1 MOTOR VEHICLE FUEL ❑3AVETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 7 DIESEL ❑ 3 CHEMICAL PRODUCT 4 OIL ❑ 1 DUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 FWARDOUS ❑ SO EMPTY ❑95 UNKNOWN 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) F IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF '// f� HAZARDOUS SUBSTANCE STORED&CAS.9 Cy S'C J r .✓ CAS.N: 1, > S� 111: TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOKA,B,C,i D . . A TYPE OF ❑1 DOUBLE WALLED ❑ 0 SINGLE WADED WITH EXTERIOR DINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ;, .❑ 1 STEEUIRON ❑ 2 STAINLESS STEEL ❑ 7 FIBERGLASS ❑4 STEEL CUD W/F18ERGlASS REINFORCED PLASTIC WTERUL,;.,., 8.TANK .',T'j"❑ 5 MOM ❑6 POL"WL040PoDE ❑ 7 AWAMET MINUM ❑6 10 HANOLCOMPATIBUFRP . ?:;.•,❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ 1 IUBBERUNED ❑2 A1(YO LRUNG ❑ 7 EPDXY LINING ❑4 PHENOUCUNING LINING. ❑ 5 GLASS LWWO ❑ 6 UNLINED ❑95 UNI09pVN '❑ IS LINING MATFRMLCOURARBIE WITH 10184 METFWgLi ❑YES ❑ NO ❑ 99 OTHER 0. CORROSION ❑ 1.POLYETRLD,EWRAP ❑2 TAI OR ASPHALT ❑ 7 VWIL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 GATHODIC?WTECTKIN ❑ 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 I SUCTION A U 2 PRESSURE A U DI 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 7 LINEDTRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IHON A U 2 STAINLESSSTEEL A U 2 POLYVINYL CHLORIDE(PVC) A U 4 FIDERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%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, P 9 1 VISUALCHECK P 4 2 INVENTORY RECONCILIATION P 9 0 VADOSE WELLS P 9 4 ELECTRONIC MONITOR P 9 5 GROUND WATER MONITORING WELLS P 9 6 PRECISION TESTING ► 9 7 PRESSURE TESTING P 9 91 NONE ► 9 95 UNKNOWN P 9 W OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF7.WAS TANK FILLED WITH OALlON9 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. APPLICANT'S NAME(PRINTED 4 SIGNATURE) PATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION• AGENCY N FACILITY ID N TANK ID N CURRENT LOCA.AQEHCY FACILITY ID F / APPROVED BY NAME PHONE#WITH AREA CODE C7OL��U PERMITHUMBER PERMIT APPROVAL DATE PERMIT EKPIMTION DATE CHECK# PERMITAMOUHT BURCHARGEAMT. FEE CODE ECEIPTa by; � '� ' FORMB(6-29,66) THIS FORM MUST BEACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM W.UNLESS A CURRFNT FAAUv' ULC Pccu u�cn