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STATE OF CALIFORNI WATER RESOURCES CONTR OARD FORM `B': UNDEVGROUND STORAGE TANK PROGRAM L... •. TANK PERMIT APPLICATION INFORMATION TANK ` $- COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ Z G MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 RMANENTLV CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED 09 FACILITY/SITE NAME WHERE TANK IS INSTALLED: [ OT03 N l0 FARM TANK-YES❑ NO /� I. TANKOESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CO G7T A. OWNERS TANK ID p B. MANUFACTURED BY00 C. YEAR INSTALLED iLl� D. TANK CAPACITY IN GALLONS: 00 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. i MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 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 ARC ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C CAS.p: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,&D A.TYPE OFIL��n1�DOUBLE WALLED F-] 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM u `SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEELPRON ❑2 8'TAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 1 DO%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ ID GALVANIZED STEEL [:D 95 UNKNOWN ❑ 99 OTHER C.INTERIOR F-11 RUBBER LINED ❑ 2 ALKYD LINING F-] 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING f�i 6 UNLINED ❑ 95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑F y3 VINYL WRAP F-14 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE U B5 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 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLOHIDE(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 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 4095 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 S I VISUAL CHECK P 8 2 INVENTORY RECONCILIATION 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS fes„/ P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 1 NONE P S 95 UNKNOWN P 8 W OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST US D(MO/YR) 2. ESTIMATED QUAPTITY OF 3. WAS TANK ffLLED WITH SUBSTANC R ING IN GALLONS INERT M ALP ❑ YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. '' APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION N AGENCY R FACILITY ID B TANK ID K rn LZ LE -I [= = 40 0 If / 1 1 o d � CURRENT OCAL AGENCY FACILITY 10 N APPROVED BY NAM PHONE N WITH AREA CODE Gtt U (!� PERMIT NUMBER PERMIT APPROVAL DATE P RMIT EkPIRATION DATE CHECKN PERMIT AMOUNT FURCHARGE AYT. FEE CODER FcIIIPTN BY: FORM B S-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS SEEN FILED DATA PROCESSING COPY