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FATE OF CALIFORNIA WATER RESOURCES CONTRO' 90ARD FORM 'B': UNDETtGROUND STORAGE TANK PROMRAM 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 PE0MANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE EP-6TANK REMOVED6 9 FACILITY/SITE NAME WHERE TANK IS INSTALLED: a1 FARM TANK-YES❑ NO ❑ 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IO# B. MANUFACTURED BY: 14 A lip. C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Q4000 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. ❑ 1 UNLEADED F]2 LEADED DIESEL ❑ B.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 FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CAS.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,a D A TYPE OF ❑1 WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER EL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 RETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 619996 METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZ ❑ 10 GALVANIZED STEEL ❑W UNKNOWN ❑99 OTHER El RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING 5 GLASS LININGC INTEIHOR LINED ❑95 UNKNOWN LINING Ed ❑ ❑IS UMNG MATERIAL COMPA WRH 106%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D CORROSION ❑ 1 POLYETHLENEWMP TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 E ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE OUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRE URE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER L CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBL ALLED 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 NkEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR NDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS • 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 95 UNKNOWN P S 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 O ONS INERT MATERIAL? E]YES 0 N THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST O MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID B TANK ID# ,3 = = 1441 ,:Z1316131O CURRENT LOCAL AGENCY FAGLITY ID N APPROVED BY NAME yQ PHONE f WITH AREA CODE G .5 PERMIT NUMBER PERMIT APPROVAL DATE PkAhirrExPiRATioNDATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE PIECE T* BY: PU FORMB(6-29-BB) THIS FORM MUST BE ACCOMPANIED�IAFACILITYMNAPCATION, FORM'x7uNLESSA ENT FORMA' HAS BEEN FILED DATA PROCESSING COPY