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STATE OF CALIFORNI,- WATER RESOURCES CONTRQ,'.jOARD �•'' FORM 'B': UNDERGROUND STORAGE TANK PROGRAM ;mom TANKTANK PERMIT APPLICATION INFORMATION TANK. COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK 10 ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORAR(TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 5'�(lJZ_/ FARM TANK-YES❑ NO ❑ N Ln I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CD A. OWNERS TANK ID# B. MANUFACTURED BY: ? C) C. YEAR INSTALLED ? D. TANK CAPACITY IN GALLONS: II. 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 P EUM B. C. ❑ 1 UNLEADED ❑2 LEADED E]3 DIESEL F-13 CHEMICAL PRODUCT OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ BO EMPTY ❑95 UNKNOWN 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF � I HAZARDOUS SUBSTANCE STORED 8 C.A.S.# 1r• C.A.S.M III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 ALU MATERIAL UM ❑B 10996 METHANOL COMPATIBLE FRP ❑9 BRONZE ❑10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER C. INTERIOR F-11 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑4 PH UNING LINING F-15 GLASS UNING El UNLINED NKNOWN ❑ IS UNING MATERAL COMPATIBLE WITH 190%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETMENEWMP ❑2TAR OR ASPHALT ❑3 W P ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:] 5 CATHODIC PROTECTION ❑91 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 U 2 PRESSURE A U 3 GRAVITY A U 91 NONE AU 5 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 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 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FISERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL CLAD W/FRP A U 8 10D%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STET 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 S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P B 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE <ZZ:;�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 SUBGALLONS STANCE REMAINING IN 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'S NAME(PRINTED B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# / -6 23 CURRENT LOCALAGENCY FACILITY WIDM✓5� APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMITAPPROVAL DATE PERMIT EXPIRATION DATE 2 CHECK PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: 1 FORMS(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY