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STATE OF CALIFORNIA• WATER RESOURCES CONTROLRD FORM `B': UNDERGROUND STORAGE TANK PROG M = � TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. o MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIMPERMIT � 4 AMENDEDPERMIT 6 TEMPORARY TANK CLOSURE �B TANK REMOVED /s FARM TANK-YES NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: Q) - I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# t/h n w B. MANUFACTURED BY: vn f(n wn C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 3 pUU a I. 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 2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT 4 OIL [all PRODUCT ❑4 GASAHOL 5 JET FUEL 0 6 AVIATION GAS 7 METHANOL Ej 99 OTHER(DESCRIBE IN ITEM D,BELOW) 5 HAZARDOUS BO EMPTY []95 UNKNOWN 2 WASTE D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑1 DOUBLE WALLED F�3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM �2 SINGLE WALLED f7 4 SECONDARY CONTAINMENT 99 OTHER 1 STEEL/IRON F7 2 STAINLESS STEEL F-�3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE F-�7 ALUMINUM 8 100%METHANOLCOMPATIBLEFRP MATERIAL ❑9 BRONZE 10 GALVANIZEQSTEEL 95 UNKNOWN E]99 OTHER 1 RUBBERUNED 2 ALKYD LINING 3 EPDXY LINING ❑ 4 PHENOUC LINING C. INTERIOR 5 GLASS LINING ❑6 UNUNED E;14 UNKNOWN LINING ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? YES 0 NO 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP F-1 2TA13 OR ASPHALT �3VINYL WRAP 4 RBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION Ej 91 NONE Ld%UNKNOWN 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, 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 5 UNKNOWN A U 99 OTHER A&1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 6100%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 Q 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 3 7 PRESSURE TESTING P 91 NONE P S 95 UNKNOWN P 8 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 / Q Q GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? YES NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. SIGNATURE) !DATE APPLICANT'S NAME(PRIN/TEDB `� /t ew/ .3 LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 06 a3 Sg 000 / CURRENT LMBOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE tle PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: CH FORM R(6-29-6B) THIS FORM MUST BE ACCOMPANIE79Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A. RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY