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TATE OF CALIFORNF 4 WATER RESOURCES CONTR( BOARD FORM 'B': UNDtAGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION VVmv-I c w �cVnnA' P rvnm v, In I nG rvLLvmnO mr nmA I Ivn rVn Cm1 n I Amm. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT at<CHANGE OF INFORMATION ❑ 7 PERMANENTLY ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: / 7 A - A, �. Q `FARM TANK -YES rANKDESCRIPTION COMPLETE ALL ITEMS -IF UNKNOWN — SO SV .IFV NO A. OWNERS TANK ID K// ❑ I DOUBLE WALLED B. MANUFACTUREDBY: C. YEAR INSTALLED LL�wL�-- D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF (A.U. IS MARKED. COMPLETE ITEM C. IF (A.11 IS NOT MARKFn COMPI FTF ITFu n A. 10'I'MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. ❑ I DOUBLE WALLED C. ❑ 1 UNLEADED DED ❑ 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. M A_� C.A.S. M Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, BID A TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER NOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER UNKNOWN A U 99 OTHER ❑ i STEEUIRON 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 AL UM ❑ 8100%METHANOLCOMPATIBLEFRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PH LINING LINING ❑ 5 GM LINING ❑ 6 UNUNED UNKNGWN A ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAO OR ASPHALT❑ ❑ 3 WNKNOWN 4 FIBERGLASSREINFORCEDPLASTIC PROTECTION ❑ 5 CATHODICPROTECTION ❑ 91 NONE U ❑ 99 OTHER IV. PIPING INFORMATION CIRCIF A IFARnVFOR(Vwn n IFIINnFRrPnIINn PnT..I..PP„r...c VI. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATIONP A. SYSTEM TYPE A U/ SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE9 UNKNOWN A U 99 OTHER P S 99 OTHER B. CONSTRUCTION A U/ SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE IPVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM 6CONCRETE A U ]STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STE 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY OR 3 FOR RFCONnARV A PRIUARV I PAW nPTFrTInu eveTeu uueT ec r,or, VI. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATIONP 8 LLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING S 91 NONE P 8 95 UNKNOWN P S 99 OTHER INFORMATION ON TANK PERMANEN SED IN PLACE 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONSINERT MATERIAL? [:]YES ❑NO THIS F( Im nnO OCCN wrvlrLt I CU UNUtH I'tIVALI Y OF 1'tHJUMY, ANL) 10 1 HE HEST OF MY KNOWLEDGE, IS TRUE AND C APPLICANTS NAME (PRINTED & SIGNATURE) DATE :AL AGENCY USE ONLY COUNTY# JURISDICTION# L=EI—J INERT LOCAL AGENCY FACILITY ID MSI/ NUMBER AGENCY # FACILITY ID B f � 3 P/ APPROVED BY NAME PERMIT APPROVAL DATE I PERMITEKPIRATION DATE CHECK# PERMITAMOUNT SURCHARGE AMT. FEE CODE TANK ID # RRECT. PHONE #WITH AREA CODE # 1 BY: FORM B (6-29-68) THIS FORM MUST BE ACCOMPANIED OVA FACILITY/SITE APPLICATION, FORM 'A', UNLESS AVORENT FORMA HAS BEEN PROCESSING COPY O