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STATE OF CALIFORNIr WATER RESOURCES CONTRO" 'JOARD " FORM 'B': UNDERGROUND STORAGE TANK PROOtRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - 1 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLANK ONE ITEM F-] 2 INTERIM PERMIT F--] 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: ZlU c , FARM TANK-YES❑ NO IV I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY �'�c C71 A. OWNERS TANK ID# O B. MANUFACTURED BY: �( ' A41 V C. YEAR INSTALLEDIf Y b D. TANK CAPACITY IN GALLONS: 12,00O 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. J�rl MOTOR VEHICLE FUEL F-12 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED u u DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL Ef 1 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,BELOM D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF ,t HAZARDOUS SUBSTANCE STORED&C.A.S.# /v �I C.A.S.#:L III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D 95 A TYPE OF I DOUBLE WALLED 3 SINGLE WALLED WITH SYSTEM 14GLE WALLED ❑4 SECONDARY CONTAINMENT EXTERIOR LINER W OTHER 1 STEELIIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNED ❑2 LINING ❑3 EPDXY UNING ❑ 4 PHENOLIC LINING C LINING INTERIOR ❑5 GLASS LINING 6 UNUNED ❑��95 UNKNOWN' ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO kr99 OTHER Vr•'� D. CORROSION ❑ I POLYETHLENE WRAP 2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASSREINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMA ION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE _ 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 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 STEEUIRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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 5 1 VISUAL CHECK P S 2INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS �. P 6 PRECISION TESTING 8 7 PRESSURE TE STING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTI TED DATE LAST USED(MO/YR) 2. ESTIMAT QUANTITY OF 3. AS TANK FILLED WITH /� SUB REMAINING IN T MATERIAL? ❑YES E] NO IJ 4iALLONB JAL THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# c) DP- 3 = 3 FCURRENTOCAL AGENCY FACILITY ID# APPROVED BY NE PHONE#WITN AREA CODE MBER PERMIT APPROVAL DATE ERMIT E PIRATION DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT BY: /— FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SIIE APPLICATION, FORM 'A',UNLESS A - RENT FORMA' HAS BEEN FILED \✓`J DATA PROCESSING COPY