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STATE OF CALIFORNN WATER RESOURCES CONTR OARD 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 NEW PERMIT ❑ 3 RENEWALPERMIT5 CHANGE OF INFORMATION ❑7 PERMANENTLYCL K ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDEDPERMIITLl6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED:?. Z 6. at/(AtajwJ /Qd tv FARMTANK-YES❑ NO z 1. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY IC A. OWNERS TANK ID# 01 B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: I"a0 CJ6>, 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. ❑ 1 UNLEADED L]2 LEADED 3 DIESEL F-11 3 CHEMICAL PRODUCT ❑4 OIL { 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&CA.S.# C.A.S.#: ;WA .111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,d D A. TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM P 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 01�SIEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑6100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ C.INIERNIR 1 RUBBER LINED ❑ 2 ALKYD LINING F-13 EPDXY LINING ❑4 PHENOLIC LINING LININS ❑5 GLASS LINING rilUNLINED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑I POLYETHLENE WRAP ❑2 TARORASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE [;�"KNOWN ❑ 99 OTHER IV. PI PINGINFORMATON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 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 C. MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 10096 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A&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. IND P S 1 VISUAL CHECK P 5 2INVENTORY RECONCILIATION P 8 3VADOSE WELLS P 8 4ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS _. P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 1 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MOYYR) 2. ESTIMATEP QUANTITY OFGALLONS 3.WASTAN FFILLEDWRH SUBST REMAINING IN INF(iTjM T IAL? ❑YES [—] NO J(J THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# oo ;,- 3 1 d, 1 ,�- I d o CURRENT LOCAL AGENCY F ITY ID# APPROV D BY AME, PHONE#WITH AREA CODE �E ISS)Z PERMIT NUMBER PERMITAPPROVALDAV PERMIT EXPIRATION DATE \�1ILI� CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT BY: FORMB(3-7-68) THIS FORM MUST BE ACCOMPANIE BYA FACILITY/SITE APPLICATION, FORM'A',UNLESS ATWENT FORMA HASBEENFILED \ DATA PROCESSING COPY -/