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STATE OF CALIFORM WATER RESOURCES CONTR(_30ARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM G:< •.L' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ___ z MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED`TANK I ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ®8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: EC MCL S N FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TA00 NK ID# B. MANUFACTURED BY: (At N W C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A_ [gr-1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 13C. ❑ 1 UNLEADED R2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL �PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL 6 AVIATION GAS ❑5 HAZARDOUS A RVEHICLE FUELENTER DO ❑80 EMPTY NAME O[] 2 WASTE 95 UNKNOWN ❑ ❑ 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IFNOj HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. ,TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,t D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH MUM UNER &95 UNKNOWN SYSTEYSINGLE WALLED 4 SECONDARY CONTAINMENT [:]2 ❑ ❑ W OTHER ❑ 1 STEDUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CIAO W/FISERGLASS REINFORCED PLASTIC B.TTANKRML ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATE ❑9 BRONZE 10 GALVANIZED STEEL ®95 UNKNOWN ❑99 OTHER C.INTERIOR F-11 RUBBER LINED 2 ALKYD UNING ❑3 EPDXY LINING 4 PHENOUC LINING LINING ❑ 5 GLASS UNING ❑6 UNUNED Rg-95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%MEfHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 MWLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ®,95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE (fP.UNKNOWN A U 99 OTHER 1 B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE 5 UNKNOWN A U 99 OTHER A U 1 STEELARON 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 STEEL CLAD W/FRP A-U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEELIQ�)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 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE 95 UNKNOWN P S 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? ❑YES ❑NO 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# 2 l ZS0 10 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE (d c PERMIT NUMBER PERMR APPROVAL DATE ERMR EIPIRATION DATE CHECK PERMIT AMOUNT SURCHARGE AML FEE CODE RECEIPT# BY: FORMB(6-29-66) THIS FORM MUST BE ACCOMPAN YAFACILRY/SREAPPLICATION, FORM 'A',UNLESSrMRRENT FORM'A' HASBEENFILED DATA PROCESSING COPY