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STATE OF CALIFORNI,"w WATER RESOURCES CONTR(.,._,dOARD "`.} '^ FORM 'B': / UNDERGROUND STORAGE TANK PROGRAM MPLETE TANK TANK PERMIT APPLICATION INFORMATION COA SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT iANGE OF INFORMATION 7 PERMANENTLY NK ONE ITEM ❑ 2 INTERIM PERMIT ❑ MENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOV /pj FACILITY/SITE NAME WHERE TANK IS INSTALLED: —SLS � FARM TANK-YES[_] NO aha zns/ ,t'A I o I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# 5 B. MANUFACTURED BY: v W C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: SD O cn II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM R. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL V, 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&C.A.S.# C.A.S.#: .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,A D A.TYPE OF ❑�DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM `SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑1 RUBBER LINED ❑ LKYO LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING C.INTERIOR ❑5 GLASS LINING V6 UNLINED ❑ 95 UNKNOWN LINING ISUNING MATERIAL COMPATIBLEWITH 100%METHANOL? ❑YES E] NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VWLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION 5_16 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE AU 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER AU 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/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. / P 1 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS NP S fi PRECISION TESTING P B 1 PRESSURE TESTING P 8 NONE P 8 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMAJE DATE L�6SSTT USED(MO/YR) 2. ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH IL X SUBSTANCE REMAINING IN ^'7� GALLONS INERT MATERIAL? ❑YES NO THIS FOEMAS AAS BEEN COMPLETED 4DER PENALTY OF PERJ Y D TO THE BESr OF YZ KNOWLEDGE,IS TRUE AND CORRECT. P LICAN 'S NAME(PRINT 8 GN TUBE) c DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 2 0 -5- d CURRENT LOCAL AGENCY FACILITY 10# APPROVED BY NAME PHONE#WRH AREA CODE tA4ARM S/ PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# By �s FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM 'A',UNLESS CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY