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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY M NEW PERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: C FARM TANK-YES❑ NO .7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY go A. OWNERS TANK IDk AIVIVe I B. MANUFACTURED BY: U14�- C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS. A II. TANK C,ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM A. 1 MOT OR VEHICLE FUEL ❑ 2 PETROLEUM B C. ❑ 1 UNLEADED 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 8 C.A.S.H C.A.S.B: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,A D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 38114GLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEMSINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CND 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 ❑99 OTHER C. INTERIOR F-11 RUBBER LINED ❑ 2 ALKYD UNING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING E3*MNED ❑95 UNKNOWN ❑IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99OTHER D.CORROSION ❑ I POLYETHLENEWRAP ❑2 RASPHALT F-] 3 VINYL WRAP ❑4 RBERGLASS REINFORCED PNS TIC 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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A / SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER ASTEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER NLEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. o P S 1 VISUAL CHECK P 8 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 8 7 PRESSURETESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1, ESTIMATED DATE L#ST USED(MO/YR) 2. ESTIMATED QUANTITY OF A�f�/ 3. WAS TANK FILLED WITH SUBSTANCE REM INING IN $(��AL' '/ INERT MATERIAL? -❑ NO OHill THIS FORM bAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION k AGENCY R FACILITY ID k TANK ID k - ® = = d 4ol 10161c-) 121- CURRENT LOCAL AGENCY FACILITY ID N APPR0 ED BY NAME /� ,/ PHONE*WITH AREA CODE N/ I(/ PERMIT NUMBER PERMIT APPROVAL DATE PER ITE% (RATION DATE CHECKk PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: Ii ' 1 FORM B(3-7-BB) THIS FORM MUST BE ACCOMPANI A FACILRY/SITE APPLICATION, FORM 'A',UNLESS~RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY