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STATE OF CALIFORNIA -wATER RESOURCES CONTROL BOARD FORM 'B': UNDE OUND STORAGE TANK PROM �� v TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 'A 5 CHANGE OF ❑7 PERMANENTLY CLOSED TANK MARK ONLY F-1 1 NEW PERMIT E]3 RENEWAL PERMIT ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: ItA X S FARM TANK-YES❑ NO ® G 1. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY IC A. OWNERS TANK IDN B. MANUFACTURED BY: b,J ,.S �•^ e( E� e5 G YEAR INSTALLED D. TANK CAPACITY IN GALLONS Q O J o I"a 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A7),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT �< GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ SO EMPTY ❑ 95 UNKNOWN 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CA.S.N C.A.S.p: zlll. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF I DGUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 S'TAINLESSSTEEL 3 FIBERGLASS ❑ 4 SIEELCLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE E:]6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ I RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PHENOUGUNING C. INTERIOR ❑5 GLASS LINING 54 6 UNLINED ❑95 UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL9 ❑YES ❑ NO ❑ MOTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2TAR OR ASPHALT ❑ 3VINYL WRAP C3,4 FIBERGLASS 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 A2 PRESSURE A U 3 GRAVITY A U 99 OTHER S.CONSTRUCTION A U 1 SINGLE WALLED A#2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCTAD W/FRP A U B 106%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 LEA IRCLED. Fp 1 VISUAL CHECK P C6� INVENTORY RECONCILIATION P S 3 VADOSE WELLS� S 4 ELECTRONIC MONIT LL E N RING WE P S6 PRECISION TESTING P 5 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P M THER ^ . VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACECkftjjqr)NihAPNl'Al TI Jp {W,Ty}{\.HEALTH 1. ESTIMATED DATE LAST USED(MO/YR) 2 SUBSTANCE QUANTITY OEMAINING IN 3 rl FglL \'�1 inrcS ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,ANDYFO BESTIOF MY KNOWLEDGE,Ij TRUE AND CORRECT. APPLICANT'S NAME)PRINTED A SIGNATURE) DATE J. MEYER U.G.T.ANALYST 2 ., 9a LOCAL AGENCY USE ONLY COUNTY X JURISDICTION R AGENCY* FACILITY ID N TANK ID N m CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE Y WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMR EXPIRATION DATE CHECKY PERMIT AYOUNT SURCHARGE AMT. FEECODE RECEIPTY BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMP BY A FACILRYISI E APPUCATION, FORM'A',UNLlSwBRENT FORMA' HAS BEEN RLED DATA PROCESSING COPY