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STATE OF CALIFORNI,! WATER RESOURCES CONTRC.OARD :FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANKTANK PERMIT APPLICATION INFORMATION TANK. Z A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH COMPLETE ...o I C MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED T NK ONE ITEM F-12 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED N FACILITY/SITE NAME WHERE TANK IS INSTALLED: 2-36tro FARM TANK-YES❑ ? I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK IDP D Uv l B. MANUFACTURED BY: U K -LID AL C. YEAR INSTALLED D. D. TANK CAPACITY IN GALLONS: ` D II. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A.0 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED � DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 15 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 O,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.R C.A.S.X: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,IS,C,6 D A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH W81OR UNER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CUD WIFIBERGLASS REINFORCED RASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 8 100%METHANOL CCMPATIBLEFRP MATERIAL ❑ 9 BRONZE ❑ 70 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER UNED 2 ALKYD UNING ❑3 EPDXY UNING ❑ 4 PHENOUC UMNG C. LIN NG R ❑5 GLASS LINING �6 UNLINED ❑ 95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLEWITH I0D%ME7HANOL2 ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYENFNE WRAP ,�2 TAR OR ASPHALT ❑3 VINYLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑ 93 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A T SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 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 95 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 114��111 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. nL. P S 1 VISUAL CHECK ®S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S d ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 0'f P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 3 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED GATE LAST USED(MONS) 2. ESTIMATED QUANTITY OF 3.WASTANKRUFJ]WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES [::] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED B SIGNATURE) DATE SS ,Sr?�hf LOCAL AGENCY USE ONLY COUNTY 3 JURISDICTION P AGENCY B FACILITY 10 3 1 TANK ID B 3q = = 10c I I � -FOo= CURENT LOCAL AGENCY FACILITY ID F APPROVED BY NA PHONE•WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK♦ PERYIT AYOUNT SURCHARGE AYT. FEE CODE ecCElpT1 BY: L' FORM B(6-29-88) THIS FORM MUST BE ACCOMP BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS aRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY