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STATE OF CALIFORNIA WATER RESOURCES CONTROL" "kARD FORM 'B': UNDERbROUND STORAGE TANK PROGR\ AJM TANK TANK PERMIT APPLICATION INFORMATION m COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ Z 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT EVcHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TA/NK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED I? w FACILITY/SITE NAME WHERE TANK IS INSTALLED: P9kN C4 FARM TANK-YES❑ NO (AJ I. TANK DESCRIPTION COMPLETE ALL ITEMS—IF UNKNOWN—SO SPECIFV ca A. OWNERS TANK ID# B. MANUFACTURED BY: U4. I W C. YEAR INSTALLED S D. TANK CAPACITY IN GALLONS: 0 II. TANK PONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM A 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB C ❑ 1 UNLEADED n 2 LEADED E] 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL PROOUCT ❑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 8 CA.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF El UBLE WALLED ❑3.6I14GLE WALLED WITH EXTERIOR LINER E]95 UNKNOWN SYSTEM EO'22 SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I'STEELPRON ❑2 STAINLESS STEEL^ 3 FIBERGLASS ❑4 STEEL CIAO W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE LUMINUM ❑B IW%MEHANOLCOMPATIBLEFRP MATERIAL F79 BRONZE ❑10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER C. INTERIOR 1 RUBBERUNED E] 2 ALKYD LINING ❑ 3 EPDXY UNE]NG HENOUC LINING i LINING '5 GLASS UNMB ,—Efr6 UNLINED Y95 UNKNOWN ❑ISUNING MATERIAL COMPATIBLEWTIH 10096 METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2TAR OR ASPHALT ❑3^WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 WJNE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMAT N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE VAT 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 5 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 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 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5ALUMINUM A 6CONCRETE A U ISTEELCLADW/FRP A U 81 DIM METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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. 6PP RV S 1VISUALCHECK S 21NVENTORECONCILIATION P 8 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS '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 COrnrnNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# Ea2l = = blol .1G / lo lob 1 CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE N WITH AREA CODE l C foyox ��z6 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 6 z6 CHECK% PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT BY: FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIE'bfY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY