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STATE OF CALIFORNIPA WATER RESOURCES CONTROI OARD 04. FORM 'B': UNDERGROUND STORAGE TANK PROMAM TANK ZE-7 TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT NGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED w FACILITY/SITE NAME WHERE TANK IS INSTALLED: 2 1 Al FARM TANK-YES NO ❑ CA) I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I A. OWNERS TANK ID# S. MANUFACTURED BY: C. YEAR INSTALLED U D. TANK CAPACITY IN GALLONS: 2wp —�D 17 IL TANKC ONTENTS 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 E:] 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑<GASAHOL ❑5 J FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN F-] 2 WASTE ❑ 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF n HAZARDOUS SUBSTANCE STORED&C.A.S.# CAS.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,&D A. TYPE OF ❑ 1 DOUBLEWAUED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 1�795 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 ME/IRON ❑2 STAINLESS STEEL ❑ 3 RBERG ❑4 STEEL CLAD W/RBERGUSS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE I J 7 MUMINUM ❑ 8100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEt95 UNKNOWN ❑ 99 OTHERC. INTERIOR '. ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED OWN i ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES F-1 OTHER D. CORROSION ❑ 1 POLYETMFNE WRAP ❑2TAR OR ASPHALT ❑ 3 W P ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHObIC PROTECTION E-]91 NONE UNKNOWN ❑ 99 OTHER IV. P ING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE I A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 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 U 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 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEEL CLAD W/FRP A U 81 OD%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 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS N1N/, P S 6 PRECISION TESTING P S I PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 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 GALLONS REMAINING IN INERT MATERIAL? E]YES E] 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY IO# TANK ID# 1 Z4 n4�1 a0 / CURRENT LOCAL AGENCY FACT TYI N APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPINATION DATE CHECK# PERM IT AMOUNT SURCHARGE AMT. FEE CODE QECEIPT# BY: /45,' FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIEOO A FACILITY/SITE APPLICATION, FORM 'A',UNLESS N.,dflENT FORMA' HAS BEEN FILED DATA PROCESSING COPY