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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK Ilz TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CL ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT '/ ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: Q / IL y� (�.PN�T<-- FARM TANK-YES❑ NO C I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A OWNERS TANK ID 9 B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS. �D IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),13 NOT MARKED,COMPLETE REM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1PRODUCT ❑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&CAS.M C.A.S.If: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑ 1 DOUBLEWAIIPD ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑%UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STE ARON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 SIEE.CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMNA ❑8100%METHANOL COMPATIBLE RTP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑%UNKNOWN ❑%OTHER [—] I RBBERUNED ❑2 ALKYD LINING F-13 EPDXY LINING F-14 PHENOLIC LINING C. INTERIOR LINING F-15 GUM LINING ❑6 UNLINED ❑96 UNKNOWN [:] IS LINING MATEIM COMPATIBLE WITH 106%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑i POLYETLENEWMP ❑2 TAR OR ASPHALT ❑3 VIWL WRAP ❑ 4 RBERGUS3 REINFORCED PUSRC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑96 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 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 1 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 U 1 STEEL/IRON A U 2 STAINLESSSTEEL 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 STEEL CLAD W/FRP A U 8 100%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 S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 3 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P E 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P B 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 E:] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION P AGENCY k FACILITY ID M TANK ID k = = I I I / 1 CURRENT LOCAL AGENCY FACILITY 10 S APPROVED BY NAME PHONE R WITH AREA CODE I PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE p 9 CHECK R PERMIT AMOUNT .SURCHARGE AMT. FEE CODE RECEIPT♦ SY:'�Vn , FORM R(6-29-eel THIS FORM MUST BE ACCOMPA c BY A FACILITY/SITE APPLICATION, FORM IAL,UNLESS A RENT FORMA' HAS BEEN FILED/!`%U// DATA PROCESSING COPY