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STATE OF CALIFORNI` WATER RESOURCES CONTRC„PiOARD _ FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. o Z 9 C MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONE ITEM ❑ 2 INTERIM PERMIT ❑ ERMIT ri 4 AMENDED PTEMPORARY TANK CLOSURE ❑B TANK REMOVED N FACILITY/SITE NAME WHERE TANK IS INSTALLED: 6D FARM TANK-YES❑ NO A I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID a _ �'0 S. MANUFACTURED BY: u01L C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: z MED H. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A. ld 1 MOTORVEHIGLE FUEL ❑ 2 PETROLEUM B. C. Cgl UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL �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.BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.N C A.S.q' III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.&D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM 02SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/RBERGIASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 5 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 8 18D%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ ID GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER ❑ I RUBBER UNED ❑2 ALKYD UNING ❑ 3 EPDXY LINING ❑4 PHENOLIC UNING C. LINING INTERIOR ❑ 5 GLASSUNING �.6 UNLINED ❑95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE NTH 180%METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP 2 TAA OR ASPHALT ❑ 3 VINYLWMP ❑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 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 U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE AG 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON 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 A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%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. S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 3 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WE LS (vim P s6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) Z ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH GALLONS SUBSTANCE 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. f f J fG APPLICANT'S NAME(PRINTED&SIGNATURE) DATE SSSJtt r LOCAL AGENCY USE ONLY COUNTY N JURISDICTION R AGENCY M FACILITY ID R TANK ID S 0 ooh 4 CURRENT LOCAL AGENCY FACILITY IDR APPROVED BY N E PHONE R WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EKPIRIITION DATE i CHECK PERMIT AMOUNT I SURCHARGEAMT. FEE CODE ecCEiPTR BY: FORM B I6-29-881 THIS FORM MUST BE ACCOMPA BY A FACILYYY/SITE APPLICAi10N, FORM 'A',UNLES3'w CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY