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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 IN ORMATION FOR EACH TANK. MARK ONLY ❑ '�PERMI7 ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION -]7 PERMANENTLY CLOSED TANK ; ONE ITEM Q12INTERIM PERMIT ❑4 AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE 08 TANKREMOVED L-J FACILITY/SITE NAME WHERE TANK IS INSTALLED: -Z�) ; -2e omi L po NJ FARM TANK-YES❑ NO 1. Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN— SO SPECIFY 10 A. OWNERS TANK ID# LI/J B. MANUFACTURED BY: C. YEAR INSTALLED (- ' D. TANK CAPACITY IN GALLONS: 000 It II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A_ 1 MOTOR VEHICLE FUEL F—] 2 PETROLEUM B. C. ❑ 1 UNLEADED LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL RRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF ,L 1 HAZARDOUS SUBSTANCE STORED a C.A.S.# N C.A.S.#: U 4— x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A. TYPE OF ❑ I DOU WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM NGLE WALLED ❑ ISECONDARY CONTAINMENT 99 OTHER 5TEBUIRON E]2 STAINLESS STEEL ❑3 FIBERGLASS E] 4 STEEL CUD W/RBERGUSS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE LE]7 AALLUM ❑8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER C. INTERIOR F-11 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LAKING ❑6 UNLINEDr�j<UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3 VI WRAP ❑4 FIBERGLASS REINFORCED PLASTIC Ii PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER I IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 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 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 GALVANIZED STEEL A 05 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 8 1 VISUAL CHECK 0152 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS �I,4' 9 P PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONEP S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST US O/VRI 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HA64EIEEN 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 10# TANK ID# ol d 2- (0 13 1 1 o LD I o 1f' CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY N MME PHONE#WITH AREA CODE 'V ` Oe- PERMIT NUMBER PERMITAPPROVAL OA PERMIT EXP TION DATE CHECK# PERMIT AMOUNT L SURCHARGE AINT. FEE CODE RECEIPT# BY: \V`Af1 FORM 8(3-7-BB) THIS FORM MUST BE ACCOMPANI&dY A FACILITY/SITE APPLICATION, FORM `A',UNLESSkVWRRENT FORMA' HAS BEEN FILED