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STATE OF CALIFORNIAWATER RESOURCES CONTR( 30ARD FORM `B': UNDIMGROUND STORAGE TANK PR06RAM TANK PERMIT APPLICATION INFORMATION TANK ; COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSE ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED /24 FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO ❑ Z 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY P y7 10 A. OWNERS TANK ID# B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 115 CA 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 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT OIL ❑ 1 PRODUCT ❑ 4 GASAHOLn 6�dET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY F-195 UNKNOWN �[WASTE ❑7 METHANOL I j� 999 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF �� O�1 HAZARDOUS SUBSTANCE STORED&C.A.S.# (� C.A.S.#: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A TYPE OF BLE WALLED F-13 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑ fi POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 1OD%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ i RUBBER UNED ❑ ALKYOUNING ❑ 3 EPDXY LINING ❑4 PHENOLIC UNI NG C.INTERIOR LINING ❑5 GLASS LINING fi UNLINED ❑ 95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL9 ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYEIHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑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 SUCTION A U 2 PRESSURE U GRAVITY A U 99 OTHER B. CONSTRUCTION U SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER U STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A V 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 A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. N P S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 3 VAOOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 5 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 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 GALLONS INERT MATERIAL? ❑YES NO THIS FORM HAS BEEN COMPLET D UNDER PENALTY OF JkIRY,AND TO THE IEST OF Y KNOWLEDGE,IS TRUE AND CORRECT dl-LUCANT'S NAME(PRIED IGNATURE) _ UL I DATE 71 Lvv rJ 1677 LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3 y os oa CURRENT LOCAL AGENCY FACILITY IO# , APPROVED BY NAME PHONE#WITH AREA CODE PE11MR'NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE f4/0 a/ 7 CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTS FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM'A',UNLESS CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY