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STATE OF CALIFORO WATER RESOURCES CONT BOARD FORM 'B':�/ UNDERGROUND STORAGE TANK PROGRAM w TANK PERMIT APPLICATION INFORMATION ` > TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING I ORMATION FOR EACH TANK. �� z MARK ONLY : ❑ I NEW PERMIT ❑3 RENEWALPERMIT 5 CHICANGE OF INFORMATION ❑ 7 PERMANENTLY CL S �j ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT [:] 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED / FACILITY/SITE NAME WHERE TANK IS INSTALLED: y L 6-2-- i4w- L�FARM TANK-YES❑ NO ❑ n; 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CcC A. OWNERS TANK ID E B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ I UNLEADED ❑2 LEADED ❑3 DIESEL ❑ 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) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.E C.A.S.If III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,i D A TYPE OF ❑ I DDDDLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ I STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC S.TANK ❑5 CONCRETE ❑6 POLYVIWLCHLORIDE ❑ 1 ALUMINUM ❑8 109%METHANOL COMPATIBLE FRP MATERIAL. ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ I PUBURLINFD ❑2 ALKYD DINING ❑ 3 EPDXY LINING ❑4 PHENOUCUNING LINING ❑ 5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ❑ IS UMNG MATERIAL COMPATIBLE WITH 10D%METHANOL? ❑YES ❑NO ❑99 OTHER F RROSION ❑ I POLYETHLENE WRAP ❑2 TAR Ofl ASPHALT ❑3 VINYL WTUP ❑ /FIBERGLASS REINFORCED FUSTIC TECTION ❑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 U 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 U 1 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 I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBEFIGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B IBD%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. LPP B I VISUAL CHECK P B 2 INVENTORY RECONCILIATION P B 3 VADOSE WELLS P B 4 ELECTRONIC MONITOR P B 5 GROUND WATER MONITORING WELLS B 6 PRECISION TESTING P B 7 PRESSURE TESTING P S 91 NONE P E 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIMATED DATE LAST USED(MO/YR) 2 .ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INEflT MgTERIAL7 ❑YES E] NO GALLONB THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY P JURISDICTION E AGENCY P FACILITY ID Y TANK IO Y � CIII I I w I zI /I o (o o � CURRENT LOCAL AGENCY FACILITY ID E APPROVED BY NAME PHONE X WITH AREA CODE N PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK X PERMIT AMOUNT BURCHARGE AMT. FEE CODE RECEIPT A BY: F)HMEIM-29-BBI THIS FORM MUST BE ACCOMPANIED BY E YACII ITV/SITE ADM mATIAW