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STATE OF CALIFORNII� WATER RESOURCES CONTRA: ',OARD FORM 'B': UNDERGROUND STORAGE TANK PROZ`,RAM m TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDTANK 1 ONE ITEM El INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED O/ FACILITY/SITE NAME WHERE TANK IS INSTALLED: S , 94AA-o l-� ��/• FARM TANK-YES V NO N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY CA) A. OWNERS TANK ID# D/ B. MANUFACTURED BY: N C.YEAR INSTALLED 5 7 't/ I D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),18 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,CqMPLETE ITEM D. A 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ W EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.# A C.A.S.#: Ai III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,d D A. TYPE OF ❑ BLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER B.TANK ❑ 1 STEELPRON ❑2 STAINLESSUEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%MEMANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 NOLIC LINING LINING E]5 GLASS LINING E]6 UNUNED NOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? F-1YES ❑ NO OTHER u D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2TAR OR ASPHALT ❑3 WRAP E]4 FIBERGLASSREINFORCEDPLASTIC PROTECTION ❑5 CATHODICPROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF AB GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A SUCTION A PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION U SINGLE WALLED A U 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) A U 4 FIBERGLASSPIPE A U 9/ NONE C. MATERIAL A U 5ALUMINUM AAA U 7STEEL CUD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 95 UNKNOWN A U 99 OTHER �L. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. SP VISUALCHECK P' S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S PRECISION TESTING 8 7 PRESSURETESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIM TED DATE UST USED(MO/YR) 2. ESTIMATE QUANTITY OF 3.WA ANK FILLED WITH SUBSTA E REGALLONS MAIMING IN I ATERIAL? ❑YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY 6F PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION# AGENCY# FACILITY ID# TANK ID# I 6 Z 6 1010 101 /1 CURREL17yOCAl AGENCY FACT D• APPI 77 8Y NAMES 2/ PNONE N WITH AREA CODE PERMIT NUMBER(/ PERM APPNO AL DA L/� PERMIT EXPIRATION DATE 1 '71`2_ CHECKM PERMIT AMOUNT SURCHARGE AMT. FEECODE RECEIPTN SY: FORM B(5-z9-8s) THIS FORM MUST BE ACCOMPANIED-BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS AMRRENT FORMW NAS BEEN FEED DATA PROCESSING COPY