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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ° FORM `B': UNDERGROUND STORAGE TANK PROGRAM ' TANKTANK PERMIT APPLICATION INFORMATION + b COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑1 NEWPERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLYC ONE ITEM E216NITERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED D Z /n ?', _✓ TANK-YES❑ NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: 'C .1'�Z,(� FARM IC I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK IDB B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 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 8. G ❑ 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 REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.B: HAZARDOUS SUBSTANCE STORED&C.A.S.B 141 A All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑96 UNKNOWN SYSTEM r 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEELIIRON ❑2 STAINLESSSTEEL ❑3 FIBERGLASS ❑4 STEELCLADINPI081GUISS REINFORCED PLASTIC 8.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑6 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BIDNZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑1 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHEWUC UNING C. INTERIOR 5GIASS LINING UKUNUNED 095 UNKNOWN LINING ❑ "�-' ISUNINGMAT871ALCOMPATIKENTHlW%XMWiDL? ❑YES ❑NO —1 99 OTHER ❑ D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2TAR OR ASPHALT ❑3VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U- SUCTON A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION 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 TPVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A 8 CONCRETE A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A U 95 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. • P VISUAL CHECK P 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S PRECISION TESTIN B 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED ATE LAST USED(MO/YR) 2. ESTIMA DQUANTITY OF 3. WASTA F,I EDWITH ✓1„/ SU C REMAINING IN GALL INET A E�IF,L? ❑YES ❑ NO THIS FOAM HAS BEEN COMPLETED UNDER PENALTY dFPERJURY,AND TO THE BEST OF MY KNOWLEDGE,,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY B JURISDICTION B AGENCY B FACILITY ID N TANK ID R O 10 1 L 3 1010 16 11-1 CURRENT LOCAL AGENCY FACILITY ID N APPR BY E PHONE N WITH AREA CODE US CEO 11 1 $ ALL PERMITNUMBER PER IT OVAL DA PERMIT EXPIRATION DATE L� 1 CK* PERMIT AMOUNT SURCHARG A T CHE . FEE CODE RECEIPTN BY: FORM B(3a-ee) THIS FORM MUST BE ACCOMPAI DIY A FACILITY/SITE APPLICATION, FORM `A',UNLESS ;BRENT FORMA HAS BEEN FILED DATA PROCESSING COPY TUB