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STATE OF CALIFORNI!` WATER RESOURCES CONTROL -3ARD FORM 'B': UNDERGROUND STORAGE TANK PRONAM ' TANKTANK PERMIT APPLICATION INFORMATION TANK. COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH C MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ®5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK IC ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: AGO l=A GI l � � � FARM TANK-YES NO _ N I G / kvtr3� �� N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 2zS S t ' co A. OWNERS TANK IDK B. MANUFACTURED BY: E E S C.YEAR INSTALLED Iq D. TANK CAPACITY IN GALLONS: O00 110 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ® I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ® 1 UNLEADED ®2 LEADED ❑3 DIESEL 4 GASAHOL 5 JET FUEL 6 AVIATION GAS ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ® 1 PRODUCT ❑ ❑ ❑ ❑ 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.N C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&O A.TYPE OF ® 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ I STEBUIRON ❑ 2 STAINLESS STEEL ® 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑ 6 POLYVINYLCHLORIDE F-17 ALUMINUM F-18100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ MOTHER ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOUC LINING C.INTERIOR LINING ❑ 5 GLASS LINING ®6 UNLINED ❑M UNKNOWN - ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ I POLYERILENE 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 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 AU 2 DOUBLE WALLED A U 3 LINED TRENCH 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) As 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 S 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 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P 8 91 NONE P S 95 UNKNOWN P S W OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) • 1 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH 1v/A. SUBSTANCE REMAINING IN W& GALLONS INERT MATERIAL9L'j/11 ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDE NAL F ERJ ND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED B SIGNATURE) DATE PAUL, Com, WI L.TDAJ LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY IDN TANK 10 N CURRENT LOCAL AGENSCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE ZZ PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EKPIRATION DATE CHECK# PERMIT AMOUNT J.SURCHARGE AMT. FEE CODE RECEIPT BY: `MMM FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIE A FACILRY/SITE APPLICATION, FORM 'A',UNLESS A C LENT FORMA' HAS BEEN RLED DATA PROCESSING COPY