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STATE OF CALIFORNIA WATER RESOURCES CONTROL )ARD FORM B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION (az COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 10 MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM F--12 INTERIM PERMIT ©4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑.BTAAK REMOVED UQ FACILITY/SITE NAME WHERE TANK IS INSTALLED: L oir Ed oy FARM TANK-YES❑ NO IV I. TANK DESCRIPTION COMPLETEALL ITEMS-IF UNKNOWN-SO SPECIFY 00 A. OWNERS TANK ID# B. MANUFACTURED BY: a) C. YEAR INSTALLEDOL D. TANK CAPACITY IN GALLONS: U II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL F-12 PETROLEUM B. C. ❑ 1 UNLEADED LEADEO ❑ 3 DIESEL ❑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 S C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A. TYPE OF ❑ 1 DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEELARON ❑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 F-11 RUBBER LINED ❑ 2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOUC LINING C. LINING R ❑5 GLASS LINING ❑ 6 UNLINED95 UNKNOWN I ,� Il_i'L ❑ IS LINING MATERIAL COMPATIBLE NTH 100%METHANOL? ❑YES ❑ NO �ER v` D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC f PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE KNOWN ❑ 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 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 U 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 5ALUMINUM ACONCRETE A U 7STEEL CLAD WERE A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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. p ' ' VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3VADOSE WELLS 4ELECTRONIO MONITOR P S 5 GROUND WATER MONITORING WELLS P S I PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE 95 UNKNOWN P S 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 ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# F5-Tq-1 = = I oag o vob CURRENT LOCAL AGENCY FACILITY IDN /1 „�-1 I� �_ APPROVED NAME PERMIT APPROVAL !� PHONE N WITH AREA CODE PERMIT NUMBER �KJK `PPROVAL DATE PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT I AURCHARGE AMT. FEE CODE ^'CEIPT N BY: FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY