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STATE OF CALIFORNIA WATER RESOURCES CONTROL ')ARD FORM 'B': UNDERGROUND STORAGE TANK PROMAM ;-� TANK TANK PERMIT APPLICATION INFORMATION � COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. t0 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TAN ONE ITEM ❑ 2 INTERIM PERMIT F-] 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED ES I �! FACILITY/SITE NAME WHERE TANK IS INSTALLED: 5 FARM TANK-YNO N I.a I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# T I B. MANUFACTURED C.YEAR INSTALLED 14 1 D. TANK CAPACITY IN GALLONS: Q IL TANK CONTENTS IF IRA),IS MARKED,COMPLETE ITEM C.IF IAT),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL 2 P EUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ OIL 1 PRODUCT ❑4 GASOHOL ❑ 5 JET FUEL ❑6 AVIATION GAS III ❑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 `/ _ I Q HAZARDOUS SUBSTANCE STORED 8 CA.S.# Y (y-(� C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,S D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN 'I SYSTEM ❑2 SINGLE WALLED ❑d CWAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESSft ❑3 FIBERGLASS ❑4 STEEL CLAD W/FlBEAGUSS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLC ORDE ❑7 ALUMINUM ❑B IOD%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER LINED ❑2 ALKYD LINING F-13 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑ 5 GU55 LINING ❑6 UNLINED ❑95 UNKNOWN ❑ISUNING MATERIAL COMPATIBLE WITH 10D%METHANOL? YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2TAR OR ASPHALT VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE E:] UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UND GROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A3 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 U lq LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 OLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 S EL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 0 ER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDA ,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P S 4 ECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P S 95 KNOWN P 3_99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MOYYR) 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 S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# - = = IDIOM ?= 10160171 CURRENT CAL AO NCY FACILITY N I APPROVED BY NAME QI�LJ PHONE N WITH AREA CODE A/( S PERMIT NUMBER �7 PERMIT APPROVAL DATE I PqkMIT EXPIRATION DATE CHECK N PERMR AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N Bv: FORM R(6-29-66) THIS FORM MUST BE ACCOMPANIED L`fACILITY/SITE APPLICATION, FORM 'A',UNLESS A C6961T FORMA' HASBEENFILED DATA PROCESSING (7J