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STATE OF CALIFORNO WATER RESOURCES CONTR�OARD ;. :;.•. FORM 'B': UNDERGROUND STORAGE TANK PROGRAM `' - m' TANK TANK PERMIT APPLICATION INFORMATION ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING ORMATION FOR EACH TANK. - , z 10 MARK ONLY ❑ 1 NEWPERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION �❑ 77 PERMANENTLY CLO NK ONE ITEM F-] 2 INTERIMPERMIT ❑ 4 AMENDEDPERMI7 6 TEMPORARY TANK CLOSURE I 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO (� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY cylW A. OWNERS TANK ID B. MANUFACTURED BY y� A C. YEAR INSTALLED U D. TANK CAPACITY IN GALLONS: II. TANK 9ONTENTS 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 Ef`3'��DIESEL ❑ 3 CHEMICAL PRODUCT E]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) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CA S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A. TYPE OF ❑ UBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 25IGLEWALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER Irl STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEELCLAO W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER UNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 ENOUC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO �990THER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 LWRAP ❑4 RBERGUSS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODICPROTECTION ❑91 NONE EY95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A tY 3 GRAVITY A U 91 NONE A U 95UNKNOWN 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 A19 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 MERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A6 CONCflETE A U 7 STEEL CLAD W/FRP A U B 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. Y S 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS N 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 GALLONS INERT MATERIAL? E]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# 3q 1010 61 fl 11 1010101-11 CURRENT LOCAL AGENCY FACILITY 10# "PROVED BY NAME /•' PHONE#WITH AREA CODE dM6 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPTN BY: FORMB(6-29-68) THIS FORM MUST BEl.000MPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HASBEENFILED DATA PROCESSING COPY