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STATE OF CALIFORNI 4 WATER RESOURCES CONTRC IOARD FORM 'B': UNDMGROUND STORAGE TANK PRO_dRAM ' TANK TANK PERMIT APPLICATION INFORMATION (a COMPL -SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. -— Z 1� MARK ONLY NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CL.�AN ❑ ❑ ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVET ILS FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY O A. OWNERS TANK IDR 42 1 B. MANUFACTURED BY: 5�&N C. YEAR INSTALLED /I irz 1 0. TANK CAPACITY IN GALLONS: ff&&-z9 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. F7 1 MOTOR VEHICLE FUEL 2_9ETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT 4 OILRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL T-W99 OTHER(DESCRIBE IN ITEM 0.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.P IAS 6Q�H O/L— C.A.S.k: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,&D A TYPE OF I DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS [&<s—rEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑8 IDA METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL E] 95 UNKNOWN E]99 OTHER ❑ C. INTERIOR 1 RUBBER LINED ❑2 ALKYD LINING 3 EPDXY LINING F-14 PHENOLIC LINING � LINING ❑ 5 GLASS LINING ❑6 UNLINED � "UN OWN [:j IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? ❑YES ❑NO OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT 3 V1 P ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE EL4UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 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) ol 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CUD W/FRP A U 810096 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 S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS ; S5 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P b 6 PRECISION TESTING P S 7 PRESSURETESTING P 8 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑ YES E] 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 R JURISDICTION M AGENCY N FACILITY ID B Y110 TANK ID t '� = E= y / a CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE F WITH AREA CODE PERMIT NUMBER PERMITAPPROVAL DATE kERMIT EXPIRATION DATE NFILEDi CHECKN PERMIT AMOUNT '?CHARGE ANT. FEE CODE R' -'PTA,� ��FORMB(6-29-88) THIS FORM MUST BE ACCOMPANR*SPA FACILIT7/sm APPLICATION, FORM 'A',UNLESS A�,_AIEFR FORMA' HAS BE DATA PROCESSING COPY