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i • STATE OF CALIFORV \ WATER RESOURCES CONTE BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM m „ ' TANK TANK PERMIT APPLICATION INFORMATION e COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ - Z !CD MARK ONLY ❑ I 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 ❑B TANK REMOVED 0 N FACILITY/SITE NAME WHERE TANK IS INSTALLED: AZI NI alj� az FARM TANK-YES❑ NO 41h I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY r► A. OWNERS TANK ID N B. MANUFACTURED BY: N C. YEAR INSTALLED - D. TANK CAPACITY IN GALLONS: G II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. fl MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. 1 UNLEADED 2 LEADED DIESEL F-1B.3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,VENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.N C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.8 D A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ©2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEL/IRON ❑ 2 STAINLESS STEEL ❑3FIBERGIASS ❑4MEL CUD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER UNED ❑�2 ALKYDUNING F-13 EPDXY UNING [—]4 PHENOLIC LINING LINING F-15 GLASS UNING 2°UUNLINED ❑95 UNKNOWN ❑ IS UNING MATERNAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP TAR OR ASPHALT ❑3VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ S O4THODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IFAPPLICABLE A SYSTEM TYPE A LA 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 U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CUD W/FRP A U 8 1 W METHANOL COMPATISLE FRP A U 9 GALVANIZED STEEL A Q 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 1VISUAL CHECK C9 2 INVENTORY RECONCILIATION P S 3VADOSEWELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING P S 7 PRESSURE TESTING 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE UST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH P4 I GALLONB SUBSTANCE REMAINING IN 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# 101011 (c G 66 3 CURRENT LO AGENCY FACT TY IDN APPROVE BY NAME PHONE#WITH AREA CODE PERMIT NUMBER FEIIMITAPPROVAL DATE IIERMIT EXPIRATION DATE \ CHECK# PERMIT AMOUNT SURC RANGE AMT. FEE CODE RECEIPT# BY: S FORM B(6-29-66) THIS FORM MUST BE ACCOMPANI A FACILITY/SRE APPLICATION, FORM 'A',UNLESS A RENT FORMA HAS BEEN FILED DATA PROCESSING Cis