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STATE OF CALIFORNI WATER RESOURCES CONTRC 30ARD FORM 'B' UNDERGROUND STORAGE TANK PROnRAM TAN TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. -, Z MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C1 O07 R1ak� ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ) ,p❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED �� CC//JJ�S FACILITY/SITE NAME WHERE TANK IS INSTALLED: , Rd- FARM TANK -YES ❑ NO L TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN — SO SPECIFY A. OWNERS TANK ID# B. B. MANUFACTURED BY: ❑ 3 CHEMICAL PRODUCT 4 OIL ❑ C. YEAR INSTALLED ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS D. TANK CAPACITY IN GALLONS 4660 ❑ 2 WASTE 11. 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-]2 PETROLEUM B. C. �i UNLEADED E] 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT 4 OIL ❑ ��iPRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ SO EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) D C.A.S. #: >� HAZARDOUS SUBSTANCE STORED & C.A.S. 4OF AI % III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN SOX A, SI a D A. TYPE OF ❑ 1 PUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM [Er2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER A U 99 OTHER ET�,STEEUIRDN ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK5 CONCHEIE ❑ 6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑ B 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A F -1I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING F-]4 PHENOUC LINING C. INTERIOR LINING ❑ 5 GLASS LINING Q 8 UNLINED CONCRETE ❑ 95 UNKNOWN U 7 STEEL CLAD W/FRP A U ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑ YES ❑ NO Er990THER D. CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION �1 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV, V. F'IMINLi INF'UHMAI IUN CIRCLE A IF ABOVE GROUND, U IF UNULHGHUUNU, BOTH m APPLIGAMLC A. SYSTEM TYPE Al 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 U SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNEDTRENCH 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� CONCRETE A U 7 STEEL CLAD W/FRP A U 8100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL "7 U 95 UNKNOWN A U 99 OTHER _EAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P9 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 4' PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHEfl VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIMATED DATE /(// USED (MO/YR) 2. ESTIMATED QUANTITY OF SUBSTANCE E O IN MELONS I 3, WAS TANK FILL INERT MA WITH [:]YES ❑ NO THIS FORM HHAS 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 # TRENT LOCAL AGENCY FACILITY ID # I PERMIT NUMBER I PERMIT )CHECK# I PERMITAMOUNT I SURCHARGE AMT FACILITY ID # PPROVED BY NAME /4 (27 L)- ATE I PERMIT EXPIRATION DATE FEE CODE RECEIPT# -,......, , ..n aa, TMIR MOU MUCT RF ArrnMRlMIOPMV A cern ITYIBITF Am IrATInN FORM 'A' DAT- ^ROCESS:NG CI)PY TANK ID # nd lo PHONE # WITH AREA CODE BY: FORMA' HAS BEEN FILED