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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM r TANKTANK PERMIT APPLICATION INFORMATION TANK. COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CVMD-TAlWj ONE ITEM ®"2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED L� FACILITY/SITE NAME WHERE TANK IS INSTALLED:,t-(d l</�..i FARM TANK-YES❑ NO Z IG I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID k 6�� B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 000 W II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. Q A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL A ❑3 CHEMICAL PRODUCT ❑4 OIL 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.k C.A.S.k: N Ir 411. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.8 D A.TYPE OF ❑ I DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM @K2 SINGLE WALLED ❑4 SECONDARY CON AINMENT ❑ 99 OTHER PSTEEL/IRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR ❑1 RUBBER UNED 2 D LINING 3 EPDXY LINING F-14 PHENOLIC LINING LINING ❑5 GLASS LINING6 UNLINED ❑ 95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VI LWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑ 99 OTHER IV. PI PING INFORMATION CIRCLE AIFABOVE GROUND, UIFUNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE AU 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8108%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A U>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. J P 5 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P 8 PRECISION TESTING S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATE DATE LAST USED(MO/YR) 2. ESTIMATED O GALLONS TITY Of 3.WAS TANK FILLED WITH SUBSTAN G IN INE A L7 E]YES E-] NO THIS F RM HAS BEEN COMPLETED UNDER PENALTY OF PE JURY,AND TO THE BEST OF MY KNO WLED E,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY k JURISDICTION k AGENCY# FACILITY ID k TANK ID k Cil = = oil -3 1 (4 13 oo0 1-2 CURRENT LOCAL AGENCY FACILITY 10 k APPRE BY N#IE PHONE k WITH AREA CODE k, PERMITN BER PERM A7,1IFICIVAL DA/1TEE, PERMIT EXPIRATION DATE 1/4 L' I CNECKk PERMIT AMOUNT SURCHARG A FEE CODE RECEIPT# BY: (V'111 FORM B(3 7 881 THIS FORM MUST BE ACCOMPAAWAY A FACILITY/SITE APPLICATION, FORM 'A',UNLES/ ARENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY