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STATE OF CALIFORNIA- WATER RESOURCES CONTRO' HARD FORM 'B': UNDERGROUND STORAGE TANK PROeRAM r TANK TANK PERMIT APPLICATION INFORMATION % COMPLETE A SEPARATE FORM WITH THE FOLLOWING INF MATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT tl CHANGE OF INFORMATION ❑7 PERMANENTLY ONE ITEM ❑2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 31o ,5-s. /-t OO FARM TANK-YES NO O L TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ION B. MANUFACTURED BY: 49W C.YEAR INSTALLED 47 D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(AI),IS MMKED,COMPLETE ITEM C.IF(A.i),IS NOT MARKED,COMPLETE REN D. CIT A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED DIESEL ❑3 CHEMICAL PRODUCT ❑A OIL [gAlAODUCT ❑1 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 8 CAS.N C.A.S.N: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.8,C,&D A TYPE OF EDI W'� ❑3 SINGLE WALLED NTH EXTERIOR UNER ❑95 UNKNOWN SYSTEM [2 SINGLE WALLED ❑N SECONDARY CONTAINMENT ❑99 OTHER ❑1 SIEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑/STEEL CIAO W/RBFAGLASS REINFORCED PLASTIC B.TANK ❑5 wwji lE ❑6 POLYVINYLCHLORIDE [:]7 ALUMINUM ❑8 IW%METHANOLCOMPATIBUFRP MATERIAL ❑ ❑9 BIDNZE ❑ 10 GALVANIZED STEEL ED UNKNOWN 99 OTHER F INTERIOR ❑ I RUBBER LINED ❑2 AUND LINING ❑3 EPDXYUNING ❑{PHENOUCUNING LINING ❑5 GLASS UMNG ❑6 UNLINED ❑95 UNKNOWN ❑IS LINING MATBTLLL COMPATIBLE WITH IOD%METHANOL7 ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYEMLENEWgAP ❑2 TAR OR ASPHALT ❑3 VNYL WRAP ❑A RBERGLASSREWFORCEDPIASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLI CABLE A SYSTEM TYPE A I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER 8. CONSTRUCTION AQ 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I 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 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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 S 1VISUALCHECK P 8 2 INVENTORY RECONCILIATION P B 3VADOSE WELLSQB I ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DA7E LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF - 3.WAS TANK FILLED WITH LLONB SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO OA THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUEAND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK IO N CURRENT LOCAL AGENCY FA L= = O 9 / '\y'( �J 3,) APPROVED BY NAME PHONE F WITH MEA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKS PERYIT AMOUNT SURCHARGE AMT. FEE CODE `SEIPT E BY: LJ OHM 8(6 29 89) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A�,UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY