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STATE OF CALIFORNIP WATER RESOURCES CONTROL ')ARD y\ FORM 'B': UNDERGROUND STORAGE TANK PROG14AM ; ` TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 0 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 21 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED ` W FACILITY/SITE NAME WHERE TANK IS INSTALLED: �j'. R ° S 4.-- ,tp.N FARM TANK-YES❑ NO N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CD/ A. OWNERS TANK ID# C v Z yaq B. MANUFACTURED BY: UKN G YEAR INSTALLED uNC D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A MARKED,COMPLETE ITEM C.IF(A.1),1 NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED -!r3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑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:# C.A.S.If: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 RBERGLASS ❑4 STEEL CLAD W/FIBERGlAS6 REINFORCED PLASTIC B.TANK MATERIALF-15 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ ALUMINUM ❑B 10DRMETHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL V995 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER UNED [:j 2 ALKYD LINING ❑ 3 EPDXY LININGPHENOLIC UNING C. INTERIOR LINING ❑5 GLASS LINING F-16 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION E] 5 CATHODIC PROTECTION ❑91 NONE re�95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE AU 5 UNKNOWN A U "OTHER LL B. CONSTRUCTION A U 1 SINGLE WAED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A(S�)136 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 S 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS —P)s 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 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 OF 3. WAS TANK FILLED WITH 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY C�.00UNTTYY## ILII JURISDICTION# ILII AGENCY# FACILITY ID VID��# JT'A{NK IO# joj lql j [ V O CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME / PHONE N WITH AREA CODE cwrgo / PERMIT NUMBER PERMIT APPROVAL GATE PERMIT EXPIRATION DATE \ CHECK N PER AMOUNT RURCHARGE AMT. FEE CODE —CEIPT# BY: \J � FORM B(6-29-M) THIS FORM MUST BE ACCOMPANIED FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CU7IRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY