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STATE OF CALIFORN6 WATER RESOURCES CONTRC ')ARD FORM 'B': UNDEFMROUND STORAGE TANK PROG-AAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z MARK ONLY ❑ I NEWPERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7,,PfF[MANENTLYCl-QajL4NK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED N FACILITY/SITE NAME WHERE TANK IS INSTALLED: Q AM 0rl7 FARM TANK-YES NO ❑ O I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# Iq I B. MANUFACTURED BY: C. YEAR INSTALLED Y' I D. TANK CAPACITY IN GALLONS'. II. TANK CATENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),HIND MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL F—] 3 CHEMICAL PRODUCT ❑ 4 OIL B. 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.# C.A.S.#: III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXX B,C,&D A. TYPE OF ❑ 1 OUBLE 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 GLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ B 1DD%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C INTERIOR ❑ 1 RUBBER UNED ❑2 ALKYD UNING ❑ 3 EPDXY DINING 4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑ 6 UNUNED NKNOWN ❑ ISLININGMATERIALCOMPATIBLEwTH100%METHANOL? 0E ED No 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWPAP ❑2 TARORASPHALTWRAP ❑4 RBERGLASS REINFORCED PLASTIC PROTECTION [—] 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORM N CIRCLE A 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 AUNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALIFD A U 3 LINED TRENCH A U 9/ NONE A U 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 Aedlf CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL I U 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 I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS NNP S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 5 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(PRIMED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3 ' 041 1= O0 1 o CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE DiAM010 PERMIT NUMBER PERMIT APPROVAL DATE PER M IT EXPIRATION DATE CHECK# PERMITAMOUNT I SURCHARGE AMT. FEE CODE I RECEIPT# BY. /( FORMBI6-29-8el THIS FORM MUST BE ACCOMPANIED.IY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA HASBEENFILED DATA PROCESSING COPY