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STATE OF CALIFORNIA WATER RESOURCES CONTRO; PARD FORM B': UNDE ROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION ` TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK Z .o MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMI 6 TEMPORA Y ANK CL URS T K E OVED �K � N FACILITY/SITE NAME WHERE TANK IS INSTALLED: N 2UC - SAG! TD r L -Z74 FARM TANK-YES❑ NO (� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY O A. OWNERS TANK ID# p Q B. MANUFACTURED BYj/S (V �(/ '.06d CQI C. YEAR INSTALLED 9p(f D. TANK CAPACITY IN GALLONS'. 20OOO II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. I<1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. [::] l UNLEADED ❑ 2 LEADED g.3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 191 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.# CAS,#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF �1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH DOERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL 1%3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM F-] 8100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED E] 2ALKYD LINING t<3 EPDXY LINING F-]4 PHENOLIC LINING C.INTERIOR LINING ❑ 5 GLASS UNING F-16 UNLINED ❑ 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 ><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 A Q 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A(T) 3 LINED TRENCH A U 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) AO©4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/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. 1VISUALCHECK S 2 INVENTORY RECONCILIATION P 8 3VADOSE WELLS 4ELECTRONIC MONITOR P S 5GROUND WATER MONITORING WELLS 6 PRECISION TESTING S 7 PRESSURE TESTING P 8 91 NONE P 95 UNKNOWN P S 99 OTHER ` VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITYOF 3. WAS TANK FILLED WITH NA SUBSTANCE REMAINING IN GALLONS INERT MATERIAL' ❑YES E:] 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 B SIGNATURE) (JAS AMM& 'L DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION M AGENCY# FACILITY ID# TANK ID# � S 0O 0 1 / CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE � V Nca V` PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE I�Ir\ z 'L7 CHECK# PERMIT AMOUNT SURCHARGE AMT. 7 FEE CODE RECEIPT N FORM B(6-29-w) THIS FORM MUST BE ACCOMPANIED oY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORM'W HAS BEEN FILED DATA PROCESSING COPY