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STATE OF CALIFORN \ WATER RESOURCES CONTI BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM ` TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOV ` FACILITY/SITE NAME WHERE TANK IS INSTALLED: /.5/Z �Z FARM TANK-VES NO ❑ N G I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Ln N I A. OWNERS TANK ID p r/ - B. MANUFACTURED BY: CD C. YEAR INSTALLED 'L D. TANK CAPACITY IN GALLONS. - 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 ❑3 CHEMICAL PRODUCT ❑4 OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑8O EMPTY DISISUNKNOWN ❑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.p: 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 2095 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEUIRON ❑2 STNNIEES STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 NAWAI 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑10 GALVANIZED STEEL95 UNKNOWN ❑99 OTHER I ❑ 1 RUBBERUNED ❑2 ALKYD UNWG ❑3 EPDXY LINING ❑4 PH UC LINING C.INFERIOR 5 GLASS LINING 6 UNUNm UNKNOWN LINING ❑ ❑ ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER (, D.CORROSION ❑ I POLYETHIENE WRAP ❑2 TM OR ASPHALT ❑3 W P ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE - 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U / SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A UUNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNED TRENCH A U 91 NONE A U NK WN 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 5ALUMINUM A U 6CONCRETE A U ]STEEL CLAD W/FRP A U 8100%METHANOLGOMPATIBLEFRP A U 9 GALVANIZED STEEL A 5 UNKN W A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. PS 1 VISUALCHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELE NIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P S 5 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P 8KN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO7YR) 2. ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH OALLONB SUBSTANCE REMAINING IN INERT MATERIAL? [::]YES F] 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 S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY p ITV ID# TANK ID# ILDI CUR NT LO OENCY FACILITY ID# APPROVED B PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: /`7(] FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED