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STATE OF CALIFORNIA' WATER RESOURCES CONTRO(�ARD FORM 'B': UNDERtROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION (D COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. -__ � 2O MARK ONLY D<1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY OS K ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMI TEMP ARY TA,L.A CLOSURE TNK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: ^� N Ngo / � /,(� PLAN FARM TANK-YES❑ NO PqCI1 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY ~ n^ A A. OWNERS TANK ID p 3 B. MANUFACTURED BY: C. YEAR INSTALLED OO D. TANK CAPACITY IN GALLONS. 12 000 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C N i UNLEADED ❑ 2 LEADED ❑ 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL 9 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BO 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 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEURON ❑ 2 STAINLESS STEEL X3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER LINED ❑ 2 ALKYD LINING X3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWPAP ❑2TAR OR ASPHALT E13 VINYL WRAP D4 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 U 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 3 UNEDTRENCH A U 91 NONE 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 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. P S 1 VISUAL CHECK 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS 6 PRECISION TESTING S 7 PRESSURE TE STING P 8 91 NONE P V 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY Of F 3. WAS TANK FILLED WITH /A/a SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO `/ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TOTHE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) F� �A W DePoL., DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY K FACILITY ID# TANK IO M © 023 oUo CURRENT LOCAL AGENCY FACILITY AIDN/JWly APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE \�V CHECKK PERMIT AMOUNT SURCHARGE AMT. /v FEE CODE RECEIPT# BY: c 1J FORMB(6-29-BB) THIS FORM MUST BE ACCOMPANIE YAFACILITY/SITE APPLICATION, FORM `A',UNLESSA RENT FORMA HAS BEEN FILED DATA PROCESSING COPY