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STATE OF CALIFORN16 WATER RESOURCES CONTRf IOARD FORM `B': UNDERGROUND STORAGE TANK PR(suRAM '�'`�� -' TANK TANK PERMIT APPLICATION INFORMATION ® W, IJ COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY Vi"NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED a FACILITY/SITE NAME WHERE TANK IS INSTALLED: 361 W. L)-) FARM TANK - YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID If D B. MANUFACTURED BY: C YEAR INSTALLED (4" D TANK CAPACITY IN GALLONS: U 00 0 II. TANK CONTENTS IF (A.1). IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. A g�jl MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL Q 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS [:] 80 EMPTY E:] 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. # ,/I/ C.A.S #: �/✓ III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D IV. V. S A. TYPE OF ❑ 1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM �SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER U 3 GRAVITY A U 91 NONE 1 STEEL/IRON ❑ 2 STAINLESS STEEL FIBERGLASS F-] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE ❑ 10 GALVANIZED STEEL [:] 95 UNKNOWN ❑ 99 OTHER 4 FIBERGLASS PIPE A U 91 NONE F-11 RUBBER LINED F-]2 ALKYD LINING �a-3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN U 9 GALVANIZED STEEL A ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER PIPING INFURM N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE QUANTITY OF IN A. SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER SURCHARGE AMf. A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 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 LEAK DETECTION IYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS PC)6 PRECIS'ON P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMAT D DATE LAST USED (MO/YR) 2. ESTIMATEDJ SUBST N QUANTITY OF IN FACILITY ID # oo I I I ?1-4T�:--1a 3, WAS TANK FILLED WITH INERT E IAL? El YES D NO Al A I IkAINING �� GALLONS PERMIT APPROVAL A E PERMIT EXPIRATION DATE THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF�PERJURY, AND TO THE BEST OF MY KNOWLEDUJE, IS TRUE AND CORRECT. APPLICANTS NAME (PRINTED & SIGNATURE) DATE LOCAL AGENCY LIRE ONLY COUNTY # [jW] JURISDICTION # AGENCY # FACILITY ID # oo I I I ?1-4T�:--1a TANK ID # e lo [jj CURRENT LOCAL AGENCY FACILITY ID # -1 o APPROVED BY NA E v zER PHONE M WITH AREA CODE r PERMIT APPROVAL A E PERMIT EXPIRATION DATE PERMIT AMOUNT SURCHARGE AMf. FEE CODE RECEIPT # BY: FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIM A FACILITY/SITE APPLICATION, FORM 'A', UNLESS A RRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY S