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STATE 0 P CALIFORNI _ WATER RESOURCES CONTRI,.,80ARD FORM 'B' -UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION �� ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ' 1• MARK ONLY I ),�❑ 1 NEW PERMIT. ❑ D RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 1 PERMANENTLY CL 10 ONE ITEM :,L� ❑2 WTFAIY PERWT ❑/AMENDED PERMIT. ❑ 8 TEMPOMff(TANK CLOSURE ❑B TANK REM W FACILITY/SITE NAME WHERE TANK IS INSTALLED: L, j F FARM TANK-YES \NO N 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-60 SPECIFY A OWNERS TANK ID 6 B. MANUFACTURED BY: f CD C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Y O O O . 11. TANK CONTENTS IF(A,1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM 0. A ❑ I MOTOR VEHICLE FUEL2 PETROLEUM B. C. ❑ I UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT I/N OIL. Z1 PRODUCT ❑4 GASOHOL ❑ S JET FUEL ❑6 AVIATION OAS ❑5 HAZARDOUS 111❑""" BO EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF �lLj 97� Q j/ HAZARDOUS SUBSTANCE STORED 8 CAS.6. CAS.Y: O d 111: TANK CONSTRUCTION MARKONEITEMONLYINSOXA,B,C,AD . . A TYPE OF• m ❑1.DOUBLE WALLED ❑0 SINGLE WALLED MTN EATEROR LINER ❑ 95 UNENOWN SYSTEM :.' ❑2 SOW WAL D ❑I SECONDARY COMM" ❑99 OTHER . ❑ T STEEU9i0N 0 2 STAINLESS WEL 0 RSEWAASS ❑ A S 010ADWIFIBEWAASSREWFORCEDRASTK: B.TANK ...: ; MATERUJ:,':.;❑ 5.CON(AEIE ❑6 POLYWNYLCILOROE ❑ 7 ALUYIMIM Q 6 100%4ETMANp.C04PATIBLE FRP ?:;. ❑9 BRONZE 0 10 GALVANIZED STEEL ❑95(NI'J90YAY 99 OTHER C.INTERIOR. :, .❑ 1 RUBBER LINED .. ❑2ALMUNINO ❑2 EPOKYLWOIG ❑I PHENOLICUMNO LINING; . :'...`❑ 9 GLASS UNNO ❑ 6 UN)NEO ❑95 L9Lsm ' . ❑ BLWINO MATFRLLCOWARM WITH 100%MEIIMNOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ I.POLVEDLEE WRAP . ❑2 TNI OR ASPHALT ❑2 VWYLWRAP ❑A RBERG=I EWFORCFDRASTC PROTECTION. ❑ 5 CATHODCPROTECnON ❑91 NONE ❑95 UNKIL" ❑ 99 OTHER IV, PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND.BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U S GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER S.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 9 UNEDTHENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I STEELARON A U 2 STAINLESS STEEL A U S POLYVINYLCHLORIDE(PVC) A U A FIBERGLASS PIPE A U 91 NONE C MATERIAL.'. A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U t 1909E 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 t 1 VISUAL CHECI( P 9 2 INVENTORY RECONCILIATION P t 2 VADOSE WELLS P t I ELECTRONIC MONITOR P t 5 GROUND WATER MONITORING WELLS P t 9 PRECISION TESTING P 9 7 PRESSURETESTING P 9 91 NONE P 9 95 UNKNOWN P t 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 2.WAS TANK FILLED WITH . _ SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? C]YES C—] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT, APPLICANTS NAME(PRINTED L SIGNATURE) GATE LOCAL AGENCY USE ONLY COUNTY 9 ' '.JURISDICTION 9 AGENCY 9 FACILITY ID 9 TANK ID 9 TTCURRENT LOCAL AGENCY FACT 1 I APPROVED BY NAME PHONE I WITH EA CODE . dao AR PERMIT NUMBER PERMITAPPROVAL DATE PERMIT EXPIRATION DATE v CHECK PERMITAMOUNT SURCHARGEANT. FEE CODE ECEIPTI tl1: �•,, FoRMBlea9•M) THIS FORM MUST BEACCOMPANIEO BYA FACIUTY/SITEAPPLICATION. FORMA' IINI FSS1M199FNT cnuu•.• u.o o«. � ��