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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B'- UNDERGROUND GEINFORMATIONPROGRAM AEAAPPLICATION TANK. zTANK COMPLETE ASPRE FORM WITH THE FOLLOWING I ORMATION FOR EACH 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE EIB TANK REMOVED /` W FACILITY/SITE NAME WHERE TANK IS INSTALLED: � FARM TANK-YES❑ NO TV W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY W A. OWNERS TANK ID p B. MANUFACTURED BY: LL K C.YEAR INSTALLED 1.L' D. TANK CAPACITY IN GALLONS: 55 6 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 ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 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.p C.A.S.p: i III. TANK CONSTRUCTION MA ONE ITEM ONLY IN BOX A.B,C,a D A TYPE OF ❑ 1 DOUBLE WALLED 3 SINGLE WA�WfTHOR LINER95 UNKNOWN SYSTEM ❑2 SINGLE WALLED 4 SECOND ❑ 99 OTHER ❑ 1 STEELARON STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ WINVLCHLORIDE ❑ 7 ALUMINUM ❑B 10096 METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 LVANIZED STEEL ❑95 UNKNOWN 99 OTHER ❑ 1 RUBBER LINED 2 UNING 3 EPDXY LINING 4 PHENOUC LINING C.INTERIOR 5 GLASS UNING ❑6 UNUN ❑ 95 UNKNOWN LINING ❑ ISUNING MATERIAL COMPATIBLEWITH 100%M NOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TMORASP LT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROAR, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSUR 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 WA ED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSST L A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S F SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 5 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE W LS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P R 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED INP CE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? [:]YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO E BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY p JURISDICTION p AGENCY p FACILITY ID# TANK ID p CURRENT LOCAL AGENCY FACILITY ID� APPROVED BY NAME PHONE x WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PIIRMIT EXPIRATION,DATE CHECK p PERMIT AMOUNT a�. SURCHARGE AMT. FEE CODE RECEIPT N BY: FORV R(6-29-ee) THIS FORM MUST BE ACCOMPANIEDI. ,FACILITY/SITE APPLICATION, FORM 'A',UNLESS A ENT FORMA' HAS BEEN FILED DATA PROCESSING CC