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-STATE OF CALIFORNM WATER RESOURCES CONTI,BOARD FORM 'B': UND GROUND STORAGE TANK PR RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ - 10 MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED D/ FACILITY/SITE NAME WHERE TANK IS INSTALLED: Mow Al, At4y.4FARM TANK-YES❑ NO All. W 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A A. OWNERS TANK ID# ? B. MANUFACTURED BY: C. YEAR INSTALLEDD. TANK CAPACITY IN GALLONS: li� U 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. q A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM R. C. ❑ 1 UNLEADED ❑ 2 LEADED P� 6ESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL �1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATIONGAS Y ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) ryl p L/ D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF / HAZARDOUS SUBSTANCE STORED&C.A S.# CAS #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OFILI��7_(II/� DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER E] 95 UNKNOWN SYSTEM L 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 7 STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGLASS 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 ❑ I RUBBER LINED F12 ALKYD LINING F__] 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ LINING 5 GLASS LINING F__] 6 UNLINED El95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH l00%METHANOL? YES ❑ NO ❑ 99 OTHER F OSION ❑ I POLYETHLENEWRAP 2 TAR OR ASPHALT ❑ 3 VINL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC ECTION ❑ 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 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 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM A UU-p6 CONCRETE A U 7STEEL CLAD W/FRP A U 8100%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. 5 P 1 VISUAL CHECK P 3 2 INVENTOR RECONCILIATION P 5 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS / P 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. WFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE ST USED(M /YR) 2. ESTIMATED ANTITV OF 3. WAS TA FILLED WITH j SUBST R AWING IN IN T ILLED E]YES ❑ NO GALLONS THIS FORM AS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK IO# Ob 1 16 1 as 16 CURRENT L AL OENCY FACILITY IDN APP V B PHONE#WITH AREA CODE Lm PERMIT NUMBER /(/J </l PERMITA GATE `1 PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT RCHARGE AMT. FEE CODE EIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY