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STATE OF CALIFORMA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATIONQp W E FOLLOWING IN MATION FOR EACH TANK. COMPLETE A SEPARATE FORM WITH TH FOL O H MARK ONLY ❑ I NEW PERMIT ❑G RENEWAL PERMIT El 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSAIT,y_K ONE ITEM ❑2 INTERIM PERMIT ❑1 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: zcb 5�- FARM TANK-YES❑ NO En- 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID B 0 `/` B. MANUFACTURED BY: C.YEAR INSTALLED `L I D. TANK CAPACITY IN GALLONS: C S� II. TANK CONTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A 1 MOTOR VEHICLE FUEL ❑ 2 PE M B. C. ❑ I UNLEADED ❑2 LEADED ❑ 9 DIESEL ❑ ]CHEMICAL PRODUCT OIL ❑ I P50GUtT ❑B GASAHOL ❑ S JET FUEL 8 AVIATION GAS 5 HAZARDOUS ❑ Po EMPTY ❑95 UNKNOWN WASTE ❑ 7 METHANOL 99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 1 C.A.S.1 CA.S.N: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,10 A TYPE OF ❑ I DOUBLE WAILED ❑2 SINGLE WALLED WITH EXTEROR LINER 95 UNKNOYM SYSTEM ❑2 SINOLEWALLM ❑A SECONONW'CONTANMENT ❑ 99 OTHER ❑ I STEELIMON ❑2 STAIMESSSTEEL ❑2 FIBERGLASS ❑ 1 STEEL CUD WKIBERGLISS REINFORCED PLASTIC B.TANK YMATERIALF-15 CONOETE ❑ 6 PoLYY1NfLOLomm ❑ 1 uymam E] 6 HDILMETFLWOLCOIJPATIBLEFRP ❑ 9 BRONZE ❑ 10 GALVANIZEDSTEEL 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I BASER LINED ❑2 LINING ❑2 EPoXYUNING ❑ 1 PHENOLCUNING LINING ❑5 GLASS LUNG 6 UNLINED ❑ 95 UNKNOWN ❑SLINING MATERIAL COMPATIBLEWITH I00%METHANOL? ❑YES 0 N ❑ 99 OTHER D.CORROSION ❑ 1 POLYETFLENEWRAP ❑ 2 TAR OR ASPHALT ❑9 A ❑ /RBERGLA55REINFORCEDPLASTIC PROTECTION ❑5 CATNwc PROTECTION ❑ 91 NONE ff 95 UNKWM ❑ 99 OR" IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A S GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U S LINED TRENCH A U 91 NONE A U '95,�NOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESSSTEEL A U 9 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U S IDD%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 5 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 ! I VISUAL CHECK P ■ 2 INVENTORY RECONCILIATION P ! 5 VADOSE WELLS / ! I E CTRONIC MONI/OR P ■ 5 GROUNDWATER MONITORING WELLS P !. 6 PREGSK)NTESTING P 6 7 PRESSURE TESTING P 6 91 NONE NKN P 6 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I.ESTIMATED DATE LAST U$EDIMO/YR) 2.ESTIMATED QUANTITY OFI� tJ(��77 1 WAS TANK FILLED WITH SIC- SUBSTANCE REMAINING IN 4J )f GALLONS INERT MATERIAL? ❑YES THIS FORM HAS 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 1 I JURISDICTION I AGENCY/ FACILITY 10 1 9 TANK ID 1 CURRENT LOCAL AGENCY FACILITY ID I APPROVED BY NAME PHONE I WITH AREA CODE T no ' U PERMRNUMBER PERMIT APPROVAL DATEPEP MIT EXPIRATION DATE 1 i� CHECK I PERMIT AMOUNT HARGE AMT. FEE CODE - IPI 1 BY: