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STATE OF CALIFORNIA WATER RESOURCESCONTR( 30ARD �.... FORM 'B': UNDERGROUND STORAGE TANK PROGRAM im TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVEDC...7 nv. FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO j,r J, I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 1 � �^cw A. OWNERS TANK ID# pa 0000 I I a1 L B. MANUFACTURED BY: IAAI ✓� C. YEAR INSTALLED llr1 ka1��..]n D. TANK CAPACITY IN GALLONS: S If. 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 LEADEDDIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL � PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑80`EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D: IF NOT MOTOR VEHICLE FUEQENTER NAME OF HAZARDOUS SUBSTA14CE STORED&C.A.S.# _. C.A.S.#r III. TANK CONSTRUCTION MARK ONEITEMONLYINBOKA,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH DRERIOR LINER ❑95 UNKNOWN SYSTEM &2_rSINGLE WAILED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑1 STEEL/IRON ❑2 STAINLESS STEEL 3 FIBERGLASS F748TEEL CUD W/FIBERGLASS REINFORCED PLASTIC B. TANK F-15 CONCRETE ❑6 POLYVINYL CHLY 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL R95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD UNING ❑ 3 EPOW LINING ❑4 PHENOLIC LINING C. INTERIOR LINING 5 GLASS LINING ❑6 UNLINED 5a95 UNKNOWN ❑�IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES 0 N ❑99 OTHER D.CORROSION ❑1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORM&TION IR CLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE FMAYPE SUCTIO A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHUA 1 INGLE 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 STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE L A U 5 ALUMINUM A U 6 A U ] STEELCLADW/FRP A U 810096 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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. v 5 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS U P S 6 PREGSION TESTING P S ] PRESSURE TESTING P B 91 NONE P 8 95 UNKNOWN B 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 GALLONS INERT MATERIAL? ❑YES [—] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT-IME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# m � 3 NCYFA CURRENT LOCAL AGEC T ID# O _7 APPROVE BY DAME PHONE#WITH AREA CODE PERMIT.NUMBEB. _ PERMIT AvvROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEi" BY: FORM B(6-29-ee) THIS FORM MUST BE ACCOMPANII!n A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A GVARENT FORMA' HAS BEEN FILED U'