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STATE OF CALIFORNIP WATER RESOURCES CONTRO' OARD FORM 'B': LINDEITbROLIND STORAGE TANK PROMAM ' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY IC) A. OWNERS TANK ID# / - B. MANUFACTURED BY: L(i/e C. YEAR INSTALLED LL<--fes. D. TANK CAPACITY IN GALLONS: /G 00 GN II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. Do 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.# A'R C.A.S.#: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a 0 A TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM Pl,;NGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER Lld STEEUIRON ❑2 STAINLESS STEEL ❑3 RBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-] 1 RUBBER UNE ❑ 2 ALKYD LINING F-13 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑5 GLASS LINING M6"UNUNE ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO E]1,89"OTHER Ly✓'y� D.CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TARORASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCE PLASTIC PROTECTION ❑5 CATHODICPROTECTION ❑ 91 NONE 'S5 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 W2 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 1995 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 095 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. J.Y� P 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS '1U/ P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? GALLONS I _-]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 COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANKID# oO Op 1010101S� CURRENT LOCAL GENCY FACILITY ID� APPROVED BY NAM PHONE#WITH AREA CODE PERMIT NUMBER /��F PERMIT APPROVALDA 7I PERMIT EXPIRATION DATE CHI PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTk BY: Yj/II " FORM B I3 7 88) THIS FORM MUST BE ACCOMPANIk`ra A FACILITY/SITE APPLICATION, FORM`A',UNLESS RENT FORMA' HAS BEEN FILED � J DATA PROCESSING COPY