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STATE OF CALIFORNIA WATER RESOURCES CONTRC IOARD FORM `B': UNDERGROUND STORAGE TANK PROZ;RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ L 10 MARK ONLY ❑ 1 NEW PERMIT F_� 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIMPERMIT ❑ 4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE8 TANK REMOVED ? Ln FACILITY/SITE NAME WHERE TANK IS INSTALLED: 41lOU ZF q7�y/� FARM TANK-YES❑ NO N 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY i W A. OWNERS TANK ID# U . �C B. MANUFACTURED BY: K CO C. YEAR INSTALLED 61. ,�. D. TANK CAPACITY IN GALLONS: 65 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 F-13 CHEMICAL PRODUCT rf OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS F] 5 HAZARDOUS [—]80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL EKOTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.N /0AP DULL- L/ C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1STEELIIRON ❑25TAINLESS STEEL F3FILASS ❑4STEEL CUO W/FlBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDEUM ❑8100%ME7HANOLCOMPATIBIEFRP MATERIAL9 BRONZE ❑ 10 GALVANIZED STEROWN 99 OTHER C. INTERIOR ❑ I RUBBERUNED ❑2 ALKYD UNING ❑3 EPDXY LINING ENOLICUNING LINING F-15 GLASSUNING F-16 UNUNED 95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 990TH Efl D. CORROSION ❑ i POLYETHLENEWRAP ❑2 TARORASPHALT QOWLWRAP ❑4 FlBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODICPROTECTION ❑91 NONE n 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION 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 A95 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 A 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE j C.MATERIAL A U 5ALUMINUMA U CONCRETE A U 7STEELCLADW/FRP A U 81GD%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. I 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS B 6 PRECISION TESTING P 8 T PRESSURE TESTING P 8 91 NONE 95 UNKNOWN P 8 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY# FACILITY ID# TANK ID N = = = lololzTT1_F1lolo lo 9 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE M WITH AREA CODE O PERMIT NUMBER PERMIT APPROVAL DATE 7iRMIT EXPIRATION DATE I CHECK# PEAMOUNT SURCHARGE AMT. FE RMITE CODE RECEIPTx �•T Foam 3l6 2a88) THIS FORM MUST BE ACCOMPANIED FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CUR RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY