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STATE OF CALIFORNI/" WATER RESOURCESCONTRO `OARD FORM 'B': UNDEFTGROUND STORAGE TANK PROMAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMI7 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED I FACILITY/SITE NAME WHERE TANK IS INSTALLED: �GQ / (� FARM TANK-YES❑ NO t0 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# (//V B. MANUFACTURED BY: C. YEAR INSTALLED 'y D. TANK CAPACITY IN GALLONS: Q 0 0 C f- w 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. W N A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED "-. IESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL 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.AS.#. ,y C.A.S.#: Kill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,&D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT - ❑99 OTHER " ❑ 1STEEL/IRONtop ❑2 STAINLESS STEEL ❑3 FIBERGLASS F-14 STEEL CLAD W/FIBERGLASS REINFORCED WIGB. TANK ❑5 1 ❑6 POLYVINYLCHLORIDE ❑7 ALU ❑810896 METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ' 'iY 19 GALVANIZED$TEE{'r UNKNOWN ❑99 OTHER C. INTERIOR / ❑ 1 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑4 PHE LINING LINING ❑ 5 CUBS LINING ❑6 UNLINED UNKNOWN 1 ❑IS UNING MATERIAL COMPATIBLE WITH 100%METHANOLP ❑YES RfNO 09 OTHER 1 D.CORROSION ❑ I POLYFRU EWRAP ❑2TAR OR ASPHALT ❑3 VI P ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 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 99 OTHER U UIL S.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH 03 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE IPVC) A U 4 FIBERGLA, PPE C. MATERIAL A U 5 ALUMINUM A2,R CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 'A UNKNOWN A U 99 OTHER VLEAK DETECTION SYSTEM CIRCLE.P,Fcb PwARY,6fT. FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. VP 8 1 VISUAL CHECK 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS to !x 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI., INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) : ESTIMATED QUANTITY OF 3,WAS TANK MLLE H ®(/ M SUBSTANCE,REMAINING GALLONS ING IN INERT MATERIAL ❑YES ED No THIS rbRM HAS BEEN C PLkTED UNDER PENAL F O URY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'SNAMEIPRINTED 6 SIGNATURE ` DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# = E:= ol ol / w- v 1-3 oo 101 CURRENT LOCAL OENOYFAQCIL APPROVED BY 1Q �� PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APROYALDATE ERMIT EKPIP TION DATE CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED FACILITYISITE APPIJCATION, FORM`A',UNLESS A CUm4ENT FORMA' HAS BEEN FILED DATA PROCESSING COPY