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STATE OF CALIFORNIO WATER RESOURCES CONTRO' `OARD FORM B': UNDERGROUND STORAGE TANK PROD-RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ___- z MARK ONLY 21 NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK I p ONE ITEM ❑ 2 INTERIMPERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARYTANK CLOSURE 01 TANK REMOVED Q' FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO (� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY CD O A. OWNERS TANK ID# 6 1 B. MANUFACTURED BY: O YEAR INSTALLED vA- D. TANK CAPACITY IN GALLONS: II. TANK CIONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. i MOTOR VEHICLE FUEL ❑ 2 PETROLEUM C. ❑ 1 UNLEADED LEADED ❑ 3 DIESEL B. ❑ 3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑60 EMPTY ❑y 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.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARKONE ITEM ONLYIN BOXA.B,C,&D A. TYPE OF ❑ I BLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT 99 OTHER 1 STEEL/INON 2 STAINLESS STEEL ILII�3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE E]6 POLYVINYLCHLORIDE L�,7 ALUMINUM ❑B 106%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANI2pSTEE0 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑ 4 P ENOUCUNING LINING ❑5 GLASS LINING ❑6 UNLINED �,/95 UNKNOWN (J ❑ IS LINING MATERIAL COMPATIBLE WITH 100%MEMNOL? ❑YES ❑ NO LTJ99OTHER LAY It D. CORROSION ❑ 1 POLYETHLENE WRAP 2 T RORASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION LL,111 NONE ❑95 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 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION l6k SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER AU STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 1 OD%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A U 95 UNKNOWN A U 99 OTHER I 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 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 5 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 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) 2. ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES E] NO 011LLON8 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# EM = = D / 171 1010101 / 1 CURREHONE#WITH AREA CODE DCT PERMIT NUMBER PERMIT APPROVA DA PERMPFEXPIRATION ATE vo a Lq- CHECKPERMIT AMOUNT SURCHARGIf AMTJ FEE CODE ECEIPT* BY: (\� FORM B(8-29-98) THIS FORM MUST BE ACCOMPANIEb+ A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A ENT FORMA' HAS BEEN FILED J DATA PROCESSING COPY