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STATE OF CALIFORNIO WATER RESOURCES CONTROARD FORM 'B': UNDERGROUND STORAGE TANK PRO RAM TANK TANK PERMIT APPLICATION INFORMATION ° COMPLETE A SEPARATE FORM WITH THE FOLLOWING NFORMATION FOR EACH TANK. - Z 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT INKCHANGE OF INFORMATION ❑ 7 PEFIMANENTLY CLOKOPP,ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED�'1FACILITY/SITE NAME WHERE TANK IS INSTALLED: V q, W FARM TANK-YES❑ NN IV I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECT Y N A. OWNERS TANK ID# B. MANUFACTURED BY: N C. YEAR INSTALLED k D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKEDJeOMPLETE ITEM D. A Ml MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT F__] 4 OIL 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.If C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D 1 BILE WALLED F__] 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN A.TYPE OF ❑ SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER I STEELPRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 TEEL CLAD WIRBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE E]6 POLYVINYLCHLORIDE F-17 ALUMINUM B 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER C. INTERIOR �`�/ F-11 RUBBER LINED ❑ 2 ALKYD LINING F__] 3 EPDXY LINING ❑ 4fHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT VINYLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFA VE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 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 A U 5 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 5 ALUMINUM A ,U,6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FEB A U 9 GALVANIZED STEEL A UU 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. P S 1VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSEWELLS P 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WE LLS P S 6 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) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? E]YES E] NO GALLONS THIS FORM HAS 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 ID# ® 100 1 1Zo � 0003 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE vFl PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODERECEIPTN BY:Cm V 7 y f M B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED UUU"""o0 DATA PROCESSING COPY