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STATE OF CALIFORNI WATER RESOURCES CONTRC_)OARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM ' TANK COMPLETE PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ z MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWALPERMIT [216CHANGE 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: ///'1�/4%l.N FARM TANK-YES❑ NO (� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY N � O A. OWNERS TANK ID# -y—y / I B. MANUFACTURED BY: L'AT C. YEAR INSTALLED U D. TANK CAPACITY IN GALLONS: II. TANK C TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. LEADE A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM G ❑ 1 UNLEADED D ❑ 3 DIESEL r73 CHEMICAL PRODUCT ❑ B 4 OIL PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN I ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.# N C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM ❑ 2 SI2 WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEELNRON 2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE ❑ 10 GALVANIZED STEEL F]95 UNKNOWN Ej 99 OTNHEQRyL ❑ i RUBBER LINED ❑ 2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PHE LINING C. INTERIOR =KNOWN LINING ❑ 5 GLASS LINING ❑6 UNLINED NKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH IDA METHANOL? ❑YES ❑NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAO OR ASPHALT g;3 YWk WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMA ON CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER S. 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 STAINLESS STEEL 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 WIMP A U 8 10U%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL An95 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. 8 1 VISUAL CHECK 'zpS 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS 6 PRECISION TESTING P 8 7 PRESSURETESTING P 8 91 NONE P 8 95 UNKNOWN P 8 W OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED( /VR) 2. ESTIMATED QUANTITGALLONS Y OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? E]YES ❑ NO THIS FORM HAS BEE COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY IDM TANK ID M M © o I 4 CURRENT LOCAL AGENCY AGILITY IDM APPROVED BY NAME 3 PHONE TH AREA CODE V`,JI PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-ee) THIS FORM MUST BE ACCOMPANIED A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORMA' HAS BEEN FILED PROCESSING COPY