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STATE OF CALIFORNIia WATER RESOURCES CONTRO116ARD FORM 'B': UNDEICROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATIONm M. COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 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 TANK REMOVED �9 } FACILITY/SITE NAME WHERE TANK IS INSTALLED: lJ -e-'� C - �- FARM TANK-YES❑ NO 1 N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPE A. OWNERS TANK ID# U 3� 6�U ' U B. MANUFACTURED BY: Ca C. YEAR INSTALLED ' I D. TANK CAPACITY IN GALLONS: I 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 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCTOIL 1 PRODUCT ❑4 GASAHOL ❑ 5JET 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 8 C.A.S.# to Q \ C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ 1 DOUBLEWALLEO ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEMSINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER B. TANK ❑ I STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS [Q-1-STEEL CLAD W/FIBERGLASS REINFORCEDPLASTIC MATERIAL ❑S CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ C. INTERIOR 1 RUBBER LINED ❑2 ALKYD LINING E] 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASSUNING ❑ 6 UNLINED R15UNKNOWN // ❑ 13 LINING MATERIAL COMPATIBLE WITH 1 DA METHANOL? ❑YES E] NO OTHER u&k- D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TARORASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑�-B&UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION U 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 UUNKNOWN 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 5 ALUMINUM A,,", CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEELICU.-* 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 5 1VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P 5 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S fi PRECISION TESTING P 3 7 PRESSURE TESTING P S 91 NONE P 5 95 UNKNOWN P 3 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE i. ESTIMATED DATE LAST USE 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY CO� JURISDICTION � AGENCY# �FACILITY 10# TANK ID# I CURRENT LOCAL AGENCY F LT- t"-)" ,Y _ \)ft7-SCA APPROy�D�Y NAME C PHONE p WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE 1/.PERMIT EXPIRATION DATE CHECK k PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS ATURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY