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STATE OF CALIFORNI WATER RESOURCES CONTRO --OARD FORM `B': UNDERGROUND STORAGE TANK PRO RAM TANK PERMIT APPLICATION INFORMATION TANK C/ COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT [kf5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL1911177 ANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE El8 TANK REMOVED /, FACILITY/SITE NAME WHERE TANK IS INSTALLED: V' SIXX lo g,;-nw,3 FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C YEAR INSTALLED D"� D. TANK CAPACITY IN GALLONS: (J O O 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 EMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL El AVIATION GAS 5 HAZARDOUS ❑ 80 EMPTY [:] 95 UNKNOWN WASTE ❑ 7 METHANOL Ftr99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF �� HAZARDOUS SUBSTANCE STORED&C.A.S.# 5 C.A.S.#: III. TANK CONSTR TION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER F-] 1 STEEL/IRON E]2 STAINLESS STEEL 3 FIBERGLASS F]4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE F-1 6 POLYVINYL CHLORIDE ❑ 1 ALUMINUM F-] 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C NKNOWN INTERIOR ❑ 5 GLASS LINING ❑6 UNLINED r9,9 THER ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NOTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TARORASPHALTV95 INYLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A OJL 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED AU 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 CHLORIDE(PVC) <,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 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. 6 P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELL P S 4 ELECTRONIC MONITOP P S 5 GROUND WATER MONITORING WELLS 2 P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE 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 GALLONS INERT MATERIAL? ❑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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# [a] /V I ;�[n 10 10 CURRENT LOCAL AGENCY FACILITY I � APPROVED BY NAME PHONE#WITH AREA CODE r 15 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE f CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY:�� FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS 7 CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY