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STATE OF CALIFORNIA WATER RESOURCESCONTROI -OARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE P?�B TANK REMOVED 6Ci N FACILITY/SITE NAME WHERE TANK IS INSTALLED: I Q I N C .ew Qf— tool . 0t FARM TANK-YES❑ NO I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY -771 N A. OWNERS TANK ID# (njC'(J B. MANUFACTURED BY: uH C. YEAR INSTALLED E,b D. TANK CAPACITY IN GALLONS'. 3 O 00 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. 1?1 A 6ZI MOTOR VEHICLE❑ 33 CHEM CAL PRO CTL ❑ 4 OI�OLEUM 6Y1 1 PRODUCT C. 1 UNLEADED LEADED ❑ 3 DIESEL TSF ❑ 4 GASAHOL ❑5 JET FUEL ❑ 8 AVIATION GAS ❑5 HAZARDOUS 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FU T HAZARDOUS SUBSTANCE STORED&C.A:S.# A✓ C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,AD A. TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM g2r2,SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER "BUIRON ❑ 2 5TAINLESSSTEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK F-1 5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑85 UNKNOWN ❑99 OTHER ❑ 1 RUBBERUNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC UNING C. INTERIOR ❑ 95 UNKNOWN LINING ❑5 GLASS LINING 6 UNLINED ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES NO ^OTHER-C� D. CORROSION � ' POLYETHLENEWRAP ❑2 TARORASPHALT ❑3 VNYI WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMAT N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 5 UNKNOA 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 5 UNKNOWWN N A U 99 OTHER 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 U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A6> UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR 8 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P S 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 INERT MATERIAL? YES E]NO y GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# d0 ! S 1010101 / CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE E 1)P-0 C7 PERMIT NUMBER PERMIT APPROVAL DATE PERIiITEkP,lRATION DATE ICHECK# PERMIT AMOUNT SURCHARGE ANT. FEE CODE ^ECEIPT# BY: I FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORMA' HAS BEEN FILED / JJJ DATA PROCESSING COPY