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STATE OF CALIFORNIA WATER RESOURCES CONTROL F ^ARD FORM 'B': UNDERGROUND STORAGE TANK PROGH%M TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z10 1. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYC17pI9FI �� �5'� � ONE ITEM F-12 INTERIM PERMIT ❑ 4 AMENDED PERMIT [:] 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED ' ! , J FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO (n I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY ~ N A. OWNERS TANK ID p B. MANUFACTURED BY: N C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: rSD IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. F-1 1 MOTOR CLE EL A ❑ 3 CHEMICAL PIRODUCTL n 2 POETROLEUM IL ❑ 1 RODUCT C ❑4 GASAHOLD ❑ 5 ET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS U❑/80 EMPTY ❑ 95 UNKNOWN �2 WASTE ❑7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF �A. JJ HAZARDOUS SUBSTANCE STORED&C.A.S.# j,.✓[(/y`,(.. paw( CAR.#: Q III, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,d D A. TYPE OF DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM H2 SINGLE WALLED ❑4 SECONDAPYGONTAINMEM ❑ 99 OTHER 1 STEBUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER LINED ❑2 ALKYD LINING F-13 EPDXY LINING F-14 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED �UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IOD%METHANOL? ❑YES ❑NOOTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDE OU ND,BOTH IF APPLICABLE A. SYSTEM TYPE A l SUCTION A U 2 PRESSURE U GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A 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 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLADW/FRP A U 8100%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 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS B 6 PRECISION TESTIN S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER - V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATE DATE UST USED(MO/YR) 2. ESTIMATED DUAN ITY OF 3.WAS TAN FILLED WITH AN SUBSTANCE REM I G IN GALLONS INERT E L? [:]YES ❑NO `/� THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLED E,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# O � 23 CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAM PHONE#WITH AREA CODE /r i7 PERMIT NUMBER PERMIT APPROVAL A E PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RFCEIPT# BY: FORM R(e-29-66) THIS FORM MUST BE ACCOMPANIE&Wf A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A aaRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY