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STATE OF CALIFORf I WATER RESOURCES CONT _ L BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING ! FORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT E215"CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDT 1O ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: q7,a 4fjine, FARM TANK-IF YES❑ NO ❑ N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A OWNERS TANK ID# B. MANUFACTURED BY: W C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 7 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 ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# CA.S.#: III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXA,B,C,BD A. TYPE OF ❑ i D LE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER L/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CND W/RBERGNSS REINFORCED PLASTIC B. TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑B 100%METHANOL COMPATIBLE RiP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RUBBER UNED ❑2 ALKYD UNING ❑3 EPDXY UNING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNUNED UNKNOWN ❑IS UNING MATERIAL COMPATIBLE WITH 10076 METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLEIA WRAP ❑ 2 TARORASPHALT ❑3 VI WMP ❑4 RBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE 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 5 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 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A JD5 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 S 1VISUALCHECK P S 2 INVENTORY RECONCILIATION P 8 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATERMONITORI WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN 8 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OFIVA3.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,I RUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# TANK ID# - 5[0-11=--�= (P101 ol Q CU RRE CAL AGENCY FACILITY ID N APPROVED BY NAMEV-V PHONE#WITH AREA CODE _ 14-5 1 /%lj PERMIT NUMBER PERMIT APPROVAL DATE IT PE MIT EXPIRATION DATE �1 CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: IT m\WFORM a(s-29-ss) THIS FORM MUST BE ACCOMPANIED BTKFAciumsm APPLICATION, FORM 'A',UNLESS A CdKENT FORMA' HAS BEEN FILED DATA PROCESSING COPY