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m-'� ,per. mrt�a.+;.�y!4RAP87R4�-'n.p.-.. •. STATE OF CALIFORNI& WATER RESOURCES CONTROARD ;• :. FORM 'B': UNDE GROUND STORAGE TANK PRO AM - N TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWINGIN FORMATION FOR EACH TANK. _ z 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 FACILITY/SITE NAME WHERE TANK IS INSTALLED: oU vZU FARM TANK-YES❑ NO .� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECI A A. OWNERS TANK ID N ��i B. MANUFACTURED BY: co C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. 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 P LEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL F—] 3 CHEMICAL PRODUCT OIL ❑ 1 PRO CT ❑ 4 GASAHOL ❑ 5 JET FU L ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS [:] 80 EMPTY [_] 95 UNKNOWN WASTE ❑ 7 METHANOL OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OFba` HAZARDOUS SUBSTANCE STORED&C.A.S.N C.A.S.N: S III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A. TYPE OF ❑ I DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINEA UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑1 STAINLESSSTEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7A�JMNUM ❑8100%METHANOLCOMPATIBLEFRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER C. INTERIOR f—] 1 RUBBER LINED [:]2 ALKYD UNING ❑ 3 EPDXY LINING ❑ 4 PHEN LINING LINING ❑5 CUSS LINING F-16 UNLINED UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TARORASPHALT ❑3 VI ❑ 4 FIBERGLASS REINFORCED PLASRC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVE GROUND, U IF UNDER OUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A GRAVITY A U 91 NONE A U 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 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�CONCRETE A U 7STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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 I VISUAL CHECK 6)S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P 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 LASTUSED(A^ /Y ) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH 'Vim/ SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E]YES L] NO THIS FORM HAS BE COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION# AGENCY M FACILITY ID R TANK ID a = = = I oo 16521 1 olo I o CURRENT LOCA AGENCY FACILITY ID# APPROVED BY AME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PE MIT EXPIRA N DATE CHECK M PERMIT AMOUNTSURCHARGE AMT. FEE CODE RECEIPT N BY: FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIED A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CIMENT FORMA' HAS BEEN FILED DATA PROCESSING COPY