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STATE OF CALIFORNI w WATER RESOURCES CONTRC - BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION (az COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEWPERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 10 ONE ITEM F--] 2 INTERIMPERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ®,8 TANK REMOVED N FACILITY/SITE NAME WHERE TANK IS INSTALLED: " E, /e6" FARM TANK-YES❑ NO .A# I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY (� A. OWNERS TANK ID B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 50 /dOO 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A_ S1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED DIESEL F-13 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN !12 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 MARK ONE ITEM ONLY IN SOX A B,C,&D A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER AP5 UNKNOWN SYSTEM ❑2 SINGLE WALED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER F-11 STEEL/IRON ❑2 STAINLESS STEEL F-13 FIBERGLASS F-14 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLYWNYLGHLORIDE F-17 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL tg-%UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 AU(YD LINING ❑3 EPDXY LINING ❑�.4�,PHENOUCUNING LINING F-1y 5 GLASSUNING ❑ 6 UNLINED 1�UNKNOWN e ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 99 OTHER \l 0. CORROSION ❑I POLYETMENE WRAP ❑2TAR OR ASPHALT ❑�K3 VINYL WRAP F-14 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑9/ NONE Imo"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 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 5 UNKNOWN A U 99 OTHER A U 1 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 CONCRETE A U ] STEEL CLAD W/FRP A U B 10096 METHANOL COMPATIBLE FqP A U 9 GALVANIZED STEEL U 5 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 VADOOSE WELLS 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES GALLONS ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# E I UD2E Oaol CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE N WITH AREA CODE III k/N7 1� PERMIT NUMBER PERMIT APPROVAL DATE PEAMITIEXPIRATION DATE ICHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE P'CEIPT N BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM'A',UNLESS A CU ENT FORMA' HAS BEEN FILED DATA PROCESSING COPY