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7`;.s''�•':,r -:"2, -..,,�...q_•�_yti: — -•.-'-=- _.�.y, ,�,,,;. .�....r.,_,.,,.,.5,,.-! �-ir +�rj--+�--?t^-+ r. :i•-.° '-' STATE OF CALIFORNIA '- WATERr'RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION ° COMPLETE A SEPARATE FORM WITH THE FOLLOWI INFORMATION FOR EACH TANK. MARK ONLY EaEW PERMIT ❑ 3 RENEWAL PERMIT El 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TA K ONE ITEM ?)�TERIM PERMIT ❑ 4 AMENDED PERMIT ❑j TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME W14ERE TANK IS INSTALLED: FARM TANK-YFrS NO' I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNO N-SO SPECIFY 10 A. OWNERS TANK ID k B. MANUFACTURED BY: C. YEAR INSTALLED .�+ D. TANK CAPACITY IN GALLONS: 12 I /S L✓ W II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. F"s A. ❑'fMOTOR VEHICLE FUEL ❑ Z PETROLEUM B. C. UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL ❑t-rRODUCT ❑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&C.A.S.# C.A.S.#: xill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D (NS� A.TYPE OF 1�' ABLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER F-11 STEEL/IRON ❑2 STAINLESS STEEL �FIAERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR F-11 RUBBER LINED ❑2 ALKYD LINING F-13 EPDXY LINING ❑4 PHENOLIC LINING - LINING ❑5 GLASS LINING �CUNLINED ❑95 UNKNOWN, ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP RBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 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 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A 4f4 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN ' A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A FIBERGLASS PIPE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%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 S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 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 INERT MATERIAL? ❑YES [—] NO GALLONS t THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJUFX,A D TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICAI A RINT &SIGNATURE) �.�f DATE , LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3I / olTIZI U O CURRENT LOCAL AGENCY FACILITY IDN APPR V D BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK 8 PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY. FORM B(3-7-88) THIS FORM MUST BE ACCOMPANI dY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORM'A' HAS BEEN FILED -\t DATA PROCESSING COPY