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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD )� FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION -° COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. TANK Zo MARK ONLY 1 NEW PERMIT r_�3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 0 ' N 3 , FARMTANK-YES❑ NO .L . I . FACILITY/SITE NAME WHERE TANK IS INSTALLED: '/ N I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: AUSCO C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: sZJ II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A7),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL F-1 2 PETROLEUM B. C. 1 UNLEADED ❑2 LEADED - 3 DIESEL' ISI ❑3 CHEMICAL PRODUCT F-1 4 OIL 1 PRODUCT ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS 5 HAZARDOUS ❑80 EMPTY E]95 UNKNOWN 2 WASTE 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) I D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.R: A HAZARDOUS SUBSTANCE STORED&C.A.S.9 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED F-1 4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEUIRON F-1 2 STAINLESS STEEL ❑3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM 8100%METHANOL COMPATIBLE FRP MATERIAL MATER 9 BRONZE 10 GALVANIZEDSTEEL ❑95 UNKNOWN 99 OTHER , 1 RUBBER LINED 2 ALKYD LINING F-13 EPDXY LINING 4 PHENOUC LINING C. INTERIOR LINING 5 GLASS LINING P/6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? Ej YES 0 NO 0 99 OTHER D. CORROSION ❑1 POLYETHLENEWRAP 2TAR OR ASPHALT 3VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 0 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN E-]99 OTHER IV. PIPING INFORMATION CIRCLE IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A(U 1 SUCTION A 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 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 94 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER ,_Y, LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. AAP S I VISUALCHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 7 PRESSURE TESTING P 8 91 NONE 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LASTSED(MONA) 2. ESTIMATED DUAN ITY OF 3,WAS TAN FILLED WITH SUBSTANCE NK G IN INERT L? [:]YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJ RY,AND TO THE BEST OF MY KNOWLEDG ,IS TRUE AND CORRECT, APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION k AGENCY k FACILITY ID R TANK ID N I 7-1k I p lo 04- [CH!ECK RRENT LOCAL AGENCY AGILITY IDN APPROVE BYN E PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APP OV L ATE PERMIT EXPIRATION DATE o N PERMR AMOUNT SURCHARGE ANT, FEE CODE SECEIPTN BY: FORM B(6-29-8$) THIS FORM MUST BE ACCO BY A FACILITY/SITE APPLICATION, FORM W UNLESS�I^URRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY