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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION m COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED p/ FACILITY/SITE NAME WHERE TANK IS INSTALLED: �Q A,4 „c� FARM TANK-YES❑ NO N I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY r W A. OWNERS TANK ID#O B. MANUFACTURED BY:S �, �7 CD C.YEAR INSTALLED ' D, TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.T),IS MARKED,COMPLETE ITEM C.IFIL (A.1),IS NOT MARKED,COMPLETE ITEM D. A ❑�3 CHEMICAL PRODUCFF-1 I MOTOR VEHICLE L W4 POETROLEUM RODUCT C ❑ 4 UNLEADED ❑2 LEADED ❑3 DIESEL ❑ 4 GASAHOL ❑5 J FUEL ❑ 8 AVIATION GAS �J 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�rCC ^ 6r� I �� T HAZARDOUS SUBSTANCE STORED&C.A.S.# JLN C.A.S.#: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,A D A TYPE OF [ffl WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER 95 UNKNOWN SYSTEM ❑2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 MORON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ %OTHER ❑ 1 RUBBERUNED ❑2 UNING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR LINING ❑5 GLASS LINING 6 UNLINED ❑%UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑ NO m0 D.CORROSION ❑ I POLYEMLENE WRAP ❑2TAR OR ASPHALT ❑3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑ 96 UNKNOWN ❑99 OTHER IV. PIPING INFORMAT ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U 3 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 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) A04 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP Al U p 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER \VVJ LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUALCHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELL P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURETESTING P 8 91 NONE P 8 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATELAST USED(MONS) 2. ESTI TEDOUANTITYOF 3.WA TANK FILLED WITH SU A CE REMAINING IN MATERIAL? ❑YES ❑ NO GALLONS THIS RM HAS BEEN COMPLETED UNDER PENAL OF PERJURY,AND TO THE BEST OF MY KN LEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# = = moo y li I oGo CURRENT LOCAL AGENCY FACILITY ID# APP RO BY AME �' fPHONE#WITH AREA CODE S,gr�J U Z o Z` PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT AURCHARGEAMT. FEE CODE RECEIPT BY: FORM B(6.29-88) THIS FORM MUST BE ACCOMPANIED A FACILITY/SITE APPLICATION, FORM'A',UNLESS A CMRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY