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STATE OF CALIFORNI 0 WATER RESOURCES CONTRf- BOARD FORM 'B': UNDERGROUND STORAGE TANK PROrGRAM TANK TANK PERMIT APPLICATION INFORMATION ® ro COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIMPERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 4 FACILITY/SITE NAME WHERE TANK IS INSTALLED: 042- R 2 FARM TANK-YES❑ NO Eff Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 I A. OWNERS TANK IDR IVO A; B. MANUFACTURED BY: Ur- C. YEAR INSTALLED V D. TANK CAPACITY IN GALLONS: w 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. —I A. ❑ 1 MOTOR VEHICLE FUEL [--12 PETROLEUM B. G F-11 UNLEADED [ 2 LEADED 4 OI ❑3 DIESEL ❑3 CHEMICAL PRODUCT L ❑ 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN WASTE -]7 METHANOL [:] 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF IUIY�Ca HAZARDOUS SUBSTANCE STORED&C.A.S.R 011- G.44 4 .111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,ED A. TYPE OF ❑�1 DONUBLEWALLED F-13 SINGLE WALLED WITH EXTERIOR LINER EJ 95 UNKNOWN SYSTEM �IIGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER Ej��-!T'I'MRARON ❑2 STAINLESS STEEL F-13 FIBERGLASS F-14 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL Q 5 CONCRETE ❑6 POLYVINYLCHLORIDE F-] 7 AtUMINUM F-18100%METHANOL COMPATIBLE FRP 9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER F-11 RUBBERUNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING F-14 PHENOLIC LINING C. INTERIOR LINING ❑5 GLASS LINING E;�EUNLINEO ❑ 95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP [V::]2 OR ASPHALT F-13 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTIONNE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE & SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A 03 GRAVITY A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 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 8 1 DO%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER ��V11. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR 8 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 9 I VISUAL CHECK &)$ 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE- P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 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. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY R FACILITY ID R TANK ID R 00O / CURRENT LOCAL AGENCY FACILITf ID R APPROVED BY NAME <18113/w b PHONE R WITH AREA CODE O 1 0 PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE \\' CHECK k PERMIT AMOUNT SURCHARGE AMT. FEE CODE RREECEIPT# BY: vv FORM B(3-7-88) THIS FORM MUST BE ACCOMPANI1'G'tiV A FACILITY/SITE APPLICATION, FORM'A',UNLESS E&T FORMA' HAS BEEN FRED DATA PROCESSING COPY