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;;STATE OF•CALIFORNI` WATER RESOURCES CONTR( BOARD "'w �;• FORM 'B' UNDERGROUND STORAGE TANK PROGRAM ;.TANK TANK PERMIT APPLICATION INFORMATION Yid ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. z 10 MAflK ONLY f•�,.❑ I NEW PERMIT r77 RENEWAL PERMIT 5 CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSED TANK .I ONE ITEM �.-L-. ❑2INTERIM PERMIT ❑ 1 AMENDED PERMIT. ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED " G FACILITY/SITE NAME WHERE TANK IS INSTALLED:/ ('/ /� �� 1?S 1� S FARM TANK-YES NO N I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFYLo C17 A OWNERS TANK 10 N 0. MANUFACTURED BY: 077 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Li 0 II. TANK CONTENTS IF(A.T).IS MARKED,COMPLETE ITEM C.IF(AT),IS NOT MARKED,COMPLETE ITEM D. A I MOTOR VEHICLE FUEL Q 2 ROLEUM B. C. 1 UNLEADED 2 LEADED D DIESEL ❑ 3 CHEMICALPRODUCT LZ4 OIL ❑ DUCT ❑ K GASAHOL ❑ 5 J�FfUE1 ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMP1Y ❑ 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.I I,/f y�Q G A CAS.I; 1jivl 5 S III. TANK CONSTRUCTION MARKONEITEMONLYINBOXA.B.C.&D A.TYPE OF ' ❑ I DOUBLEWAEUEB 0 SINGLE WALLED WITH EXTENOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLEWALED 4 SECONDARY CONTAINMENT 99 OTHER ❑ 1 STEELARON ❑2 STAINLESS STEEL ❑ 0 RBERG-k% ❑ 1 STEEL CLAD W/FISEAGEASSREINFORCED PIASTIC B.TANK .. MATERIAL,.: 5 CONCRETE - 6 POLYVINYL CNARDE 7 ALUumm 6 100%UETRANOL COMPATIBLE FRP ` ❑ 9 BRONZE ❑ 10 GALVANIZED ME 95 UNKNOWN 99 OTHER C. INTERIOR ',. ❑ I RAWERUNED ❑ 2 ALM UNING ❑ 0 EPDXY LINING ❑ T PHENOLIC UNNG LINING., :. ❑ 5.BLAM� ❑ 6 UNLINED ❑ 95 UNKNOWN ' ❑ IS LINING MATUDI.COMPATIBLE WITH 10011 ME7NANOL7 [:]YES ❑ NO ❑ 97 OTHER D.CORROSION ❑ I.POLYERLD&WMP ❑ 2TAROR ASIMLLLT ❑ BVINYL WRAP ❑A RBERGL/SSREB(FOFIOEDPL'M)C 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 I SUCTION A U 2 PRESSURE A U 9 GRAVITY A U 91 NONE A U 95 UNKNOWN A U W OTHER 8. CONSTRUCTION A u I SINGLE WALLED A U 2 DOUBLE WALLED A U D LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEELIIRON A U 2 STAINLESS STEEL A U 7 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U SALUMINUM A U 6CONCRETE A U 7STEEL CLAD W/FRP A U 8100%METRANOL COMPATIBLE FRP A U 9 OALVANIZED 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. PP / 1 VISUAL CHECK P t 2 INVENTORY RECONCILIATION P 1 0 VADOSE WEEES P / 4 ELECTRONIC MONITOR P t s GROUND WATER MONITORING WELLS P 1 6 PRECISION TESTING P t 7 PRESSURE TESTING P 9 91 NONE P 1 95 UNKNOWN P t 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YRJ 2. ESTIMATED QUANTITY OF 7. WAS TANK FILLED WITH SUBSTANCE REMAINING IN OALLONt WENT 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 a SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY I JURISDICTION I AGENCY Y FACILITY IDI TANK ID i I I / CURRENT LOCALAUENCY FACILITY I00&5 /i APPROVED BY NAME PHONE F WITH AREA CODE PLRMITNUMBLR (�/•E•'/' PERMIT APPROVAL DATE PERMIT EXPIRATI O N DATE O CMECKI PERYITAMOUNT 9URCYIA110E AMT. REE CODE ECEIPTI tlY pN � / G � '� FORM O(8.29-88) THIS FORM MUST BEACCOMPANIED BYAFACIUTY/SITEAPPLICATION. FORM 'A' UNI F99 I rnRnPer cnuu .• u•o.«•,