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STATE OF CALIFORN& WATER RESOURCES CONTR OARD FORM 'B': UNDERGROUND STORAGE TANK PR RAM TANKTANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INF90MATION FOR EACH TANK. (az 00 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑'S c.HANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TAN ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED V FACILITY/SITE NAME WHERE TANK IS INSTALLED: Z. JZI P FARM TANK -YES ❑ NO .uv nuc nemT•Inu _.euNKM0WN-90SPFrIFV MI\f� vLJv.ur ..v.. vvmr rr,r..��......... .. _......_.... __ __ A OWNERS TANK ID # ( B. MANUFACTURED BY: C YEAR INSTALLED / D. TANK CAPACITY IN GALLONS: I Q l nneD II. TANK C NTENTS n CRUD, ETF ITFM r IF a 1l. IQ NOT MARKED. COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. ❑ 1 DOU WALLED ❑ i UNLEADED ❑ 2 LEADED 3 DIESEL F-]3 CHEMICAL PRODUCT F -1B. 4 OIL 1 PRODUCT ❑ 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. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, &'D A. TYPE OF ❑ 1 DOU WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM INGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER A U 95 UNKNOWN ❑ 1 STEELIMON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 A UM ❑ B 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GAL IZED STEEL 95 UNKNOWN ❑ 99 OTHER A ❑ 1 RUBBER LINED ALXYDUNING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS UNING F76 UNLINED A UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100% ANOL? ❑ YES ❑ NO _LR9'9 OTHER (in l� D. CORROSION ❑ 1 POLYETHLENEWRAP TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 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 JURISDICTION # i SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A --'G 1 SINGLEWALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A V 91 NONE 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 U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U B 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 VISUALCHECK --6 S 2 INVENTORY RECONCILIATION P 8 3VADOSEWELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS PA 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USIM(MO/YRI 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH IAVI A- SUBSTANCE REMAINING IN OIILLONB I INERT MATERIAL? E]YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE 6�ST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANTS NAME (PRINTED & SIGNATURE) DATE 1 f%f'AI Ar:P#dCV I14F nMI V COUNTY # JURISDICTION # AGENCY # FACILITY ID # TANK ID # CURRENT LOCAL AGENCY FACILITY ID # oN 3 APPROVED BY NAME - _ PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATIO DATE CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT # BY: 1 "777s -z9 -s8) THIS FORM MUST BE ACCOMPANY APPLICATION, FORM 'A', UNLESS RRENT FORMA' HASBEENFILED 6 DATA PROCESSING COPY w IV L ii