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STATE OF CALIFORNV' WATER RESOURCES CONTRO' 'OARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDTANK ONE ITEM ❑ 2 INTERIM PERMIT 7] 4 AMENDED PERMIT [:] 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 0 FACILITY/SITE NAME WHERE TANK IS INSTALLED: S rQ ,, FARM TANK-YES❑ NO Z 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I� A. OWNERS TANK ID# of /7 6. MANUFACTURED BY: (�K C. YEAR INSTALLED D. TANK CAPACITY IN GALLONSO W II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. 0 A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑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.p C.AS.H All. 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 EL;KSINGLEWALIED ❑4 SECONDARYOWAINMENT ❑99 OTHER i STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED SEER 95 UNKNOWN ❑ 99 OTHER ❑ C. INTERIOR I RUBBER LINED E]2 ALKYD LINING F-13 EPDXY LINING ❑4 PHENOLIC LINING LININGF-] 5 GLASS UNING 6 UNLINED ❑95 U OWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL7 ❑YES ❑ NO OTHEfl [�� D. CORROSION ❑ 1 PoLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3 V LWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U i SUCTION A CU 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 'p 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A6 CONCRETE A U ] STEEL CLAD W/FRP A U B 1fXM16 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 95 UNKNOWN A U 99 OTHER R /V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 5 P 8 1 VISUAL CHECK POS 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND W MONITORING WELLS J P 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 9 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED IMO/VRI 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑NO 1 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3 1 01 0 CURREM LOCAL AGENCY FACILITY ID# APPROVED BY NAM E^ PHONE#WITH AREA CODE E fJ 5 9 7 ,?g 'T„ PERMIT NUMBER PERMIT APPROVAL DATE I PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE �RECEIPT*FORMef3 ,1 THIS FORM MUST BE ACCOMPANIEIT6YAFACILITY/SITEAPPUCATION, FORM 'A',UNLESSRENT FORM'A' HASSEENFILED \� DATA PROCESSING COPY