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STATE OF CALIFORha . WATER RESOURCES CONTh_, BOARD . FORM 'B" UNDERGROUND STORAGE TANK PROGRAM I � r. TANK TANK PERMIT APPLICATION INFORMATION ,�, ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z 10 MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 71 - ✓tP4, Al Zed FARM TANK-YES21' NO FV C-j I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY "� L/ 3SC co A. OWNERS TANK ID p B. MANUFACTURED BY: L C. YEAR INSTALLED u D. TANK CAPACITY IN GALLONS: �j 11. TANK OONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(At), T MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL F-1 2 PETROLEUMC. E 1 UNLEADED D 2 LEADED E] 3 DIESEL B. 3 CHEMICAL PRODUCT 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BO EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL m'99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF /,((+ HAZARDOUS SUBSTANCE STORED 8 C.A.S.IF 1 C.A.S.B: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXA,B,C,BD A TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ I STEEL/IRON ❑ 2 STAINLESS STEEL F� 3FIBERGLASS 4STEEL CLAD WNIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM B 100%METHANOL COMPATIBLE FRP MATERIAL_ ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 0 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER UNER ❑ 2 ALKYD UNING ❑ 3 EPDXY LINING 4 PHENOUC LINING LINING ❑ 5 GLASS UNING ❑6 UNLINED ❑ 95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I 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 I 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 V 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 10096 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 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUALCHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS 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 B 95 UNKNOWN P 8 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 0 NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) LATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION 8 AGENCY 8 FACILITY ID 8 TANK ID N 3 CLQ o y i CURRENT LOCAL AGENCY FACILITY ID 9 APPROVED BY NAME PHONE 1 WITH AREA CODE D1 M(Tr7/ PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE GHECK4 PERMIT AMOUNT SURCHARGE AMT. FEE CODE ;CEIPTY BY. 6�j/��- � , FORMB(6.29B8) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA HASBEENFTFD