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STATE OF CALIFORN WATER RESOURCES CONTR . BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM °` TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEWPERMIT 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PE NENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE LLfirTANK REMOVED b FACILITY/SITE NAME WHERE TANK IS INSTALLED: , A 4IQ FARM TANK-YES NO ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID a I I B. MANUFACTUREDBY: (� C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: sD O! If. TANK CJONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. [0"1'MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL F-13 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ 60 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAMEOF HAZARDOUS SUBSTANCE STORED&C.A.S.X A C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ 1 DW WAILED ❑3 SINGLE WALLED WITH MRIOR UNEP ❑95 UNKNOWN SYSTEM SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER /IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4STEEL CLAD W/RBERGLSS REINFORCED PLASTIC S.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE RIP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER F-11 RIBBER LINED ❑ 2 ALKYDLINING F-13 EPDXYUNING ❑4 PHENOLIC LINING C.LIN NRGOR ❑5 GLASS UNING ❑ 6 UNUNED f S(w4OWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑A99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TARORASPHALT ❑3 VINY P ❑ 4 FIBERGLASS REINFORCED PUS RC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE LLJWrUNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U / SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A&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 AjoN UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C-MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U S /00%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 5 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. N P 8 1 VISUAL CHECK P f 2 INVENTORY RECONCIUATION P f 3 VADOSE WELLS P f 4 ELECTRONIC MONITOR P f 5 GROUND WATER MONITORING WELLS P 8 6 PflECISION TESTING P 8 ] PRESSURE TESTING f 91 NONE P f 95 UNKNOWN P 6 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? E]YES EDNO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY f JURISDICTION M AGENCY k FACIL TANK ID R 3 O 10 _ , I a 4L�l 0 10 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE I I/ a 9l/ PERMIT NUMBER PERMIT APPROVAL DATE PEAMIT EXPIRATION DATE CHECKN PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT R BY: FORM B(6-29-66) THIS FORM MUST BE ACCOMPAWI Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS`, ARENT FORMA' HAS BEEN FILED DATA PROCESSING COPY