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-T .., STATE OF CALIFORW WATER RESOURCES CONTR( 1OARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - G MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYCLO IC ONE ITEM F-1 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: a, O �( FARM TANK-YES NO ❑ N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY F� A. OWNERS TANK ID q B. MANUFACTURED BY: ZL O C.YEAR INSTALLED 64 & I D. TANK CAPACITY IN GALLONS: O II. 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 ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑60 EMPTY 95 UNKNOWN ❑ 2 WASTE ❑T METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.A D A. TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN - SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CUD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 AL INUM ❑ B 100%METMNOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER ❑ 1 RUBBERUNED ❑2 AU(YDUNING ❑3 EPDXY LINING ❑ 4 CUNING C. INTERIOR ,�,9s/ LINING F75 GLASS UNING ❑6 UNUNED UNKNOWN ❑ ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑1 POLYETH ENE WRAP ❑2 TAR OR ASPHALT ❑ 3 V WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, 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 W29 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 Aa b5 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 AU CONCRETE A U 7 STEEL CLAD W/FRP A U 8100'%METHANOL COMPATIBLEFRP 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. P S 1VISUALCHECK P 8 2 INVENTORY RECONCILIATION P 8 ELLS P 6 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 1 PRESSURETESTING 8 91 NONE P 8 95 UNKNOWN P B 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 INERT MATERIAL? YES GALLONSLLON8 ❑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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# D Doo CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME y�/� PHONE#WITH AREA CODE L � IF` PERMIT UMBEfl PERMRAPPROVALDA-m RMIT EXPIRATION DATE FHECK# PERMITAMOUNT SURCHARGEAMT. FEE CODE RECEIPT BY: ^ FORM B(6-29-80) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM`A',UNLESS A RRENT FORMA' HAS BEEN FILED J DATA PROCESSING COPY