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STATE OF CALIFORNIA* WATER RESOURCES CONTRO*ARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM ? ` TANK 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 CLOSED TANK ONE ITEM F—]2 INTERIM PERMIT F--14 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE r2 B TANK REMOVED O FACILITY/SITE NAME WHERE TANK IS INSTALLED: SID , At& q o 6CLQ FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL LIITEMS-IF UNKNOWN—SO SPECI �i 9Ci A. OWNERS TANK ID# L,-, B.B. MANUFACTURED BY: C. YEAR INSTALLED L4, D. TANK CAPACITY IN GALLONS: .SW w 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. C V A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL gCHEMICAL PRODUCT ❑ 4 OIL 211*'PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS [—]5 HAZARDOUS ❑ 80 EMPTY F] 95 UNKNOWN ❑2 WASTE E]7 METHANOL Eq<9 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OFf}L 7 Cl f F, HAZARDOUS SUBSTANCE STORED&C.A.S.# C �3as) n n'C r C.A.S.#: MI. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A. TYPE OF ❑ I DOUBLEWALLED F—]3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM IryJ`SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER �STEEUIRON ❑2 STAINLESS STEEL ❑ 3FI9ERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYMNYL CHLORIDE ❑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 PHENOLIC LINING C.INTERIOR LINING ❑ 5 GLASS LINING P<UNUNED [:]95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLEWITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYEFHLENE WRAP ❑2 TARORASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE N'KUNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE p 1 SUCTION A U 2 PRESSURE A GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A kD 95 UNKNOWN A U 99 OTHER A U / STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AUO95 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. P1 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING 03 91 NONE P S 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 M R I 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# CURRENT LOCAL A�iENC FACILITY ID It, APPROVED BY NAMErl9 PHONE#WITH AREA CODE �1 \\/ a 5 oc V/� PERMIT NUMBER PERMIT APPROVAL DATE I PERMIT EXPIRATION DATE ((( ��- CHECK# PERMIT AMOUNT Ad 1 16 SURCHARGE AMT. FEECODERECEIPT# BY: 1/ JIRM B(3-7-8e) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESSIWIRRENT FORM'A' HAS BEEN FILED - J) PROCESSING COPY