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STATE OF CALIFORNA WATER RESOURCES CONTR OARD FORM 'B': UNDERGROUND STORAGE TANK PR RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. a.- . MARK ONLY Etr9lEWPERMIT F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK O ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED o / N FACILITY/SITE NAME WHERE TANK IS INSTALLED: d Al. lJFARM TANK-YES❑ NO .�a W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY p A. OWNERS TANK ID# [ B. MANUFACTURED BYjtjpV ., cr) C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: IL TANK NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.t),IS NOT MARKED,COMPLETE ITEM D. A. fffl MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED [Ell DIESEL /y ❑ 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) q FUEL,ENTER NAME CLE D. IF NOT MOTR HAZARDOUS SUBSTIANCE STORED&C A S#OF C,AS #:*[A 7/ I III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&o A.TYPE OF ❑ 1 DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER Fdoo 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS 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 C. INTERIOR El1 RUBBER LINED ❑ 2 ALKYD LINING F-13 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING fi UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLEWITH 100%METHANOL? E]YES ❑ NO P�vl'99 OTHER K D.CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 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 II 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 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM A CONCRETE A U 7STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP ZED A U 9 GALVANISTEEL 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. /r•• Pp ( VISUAL CHECK 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 56 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( O/YR) ^ 2. ESTIMATED QUANTITY F 3.WAS TA�ILLED WITH 1 (Gf� SUBSTANCE REMAI N IN T RIAL? [:]YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJ RY,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 ID# Eilil = = I a8 1 14 lo © CURRENT LgFJAAGENC7T ID� Ap�OV BY M PHONE N WITH AREA CODE PERMIT NUMBER / P IT PERMIT EXPIRATION DATE , CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT BY: \\W' FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A=RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY