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STATE OF CALIFORNII& WATER RESOURCES CONTR OARD hay;°;'ryf FORM `B': UNDERGROUND STORAGE TANK PRO RAM TANK TANK PERMIT APPLICATION INFORMATION . COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY NEW PERMIT F—] 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: W A 4L-T'5 U Q 10 ki -1 jp S 4- FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY I C1 A. OWNERS TANK ID# CJ B. MANUFACTURED BY: M� �� C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS W IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. w A. �MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. 1 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 "�J 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.# C.A.S.#: XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF . —DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 1 ALUMINUM ❑8 100%METHANOLCOMPATIBLEFRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR F—] 1 RUBBER LINED F-12 ALKYD LINING F—] 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING �Z_6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 10D%METHANOL? ❑YES [—] NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP FIBERGLASS REINFORCED PLASTIC PROTECTION ❑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 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A V 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE(PVC) Ae-04 FIBERGLASS PIPE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%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. P S 1 VISUAL CHECK & S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS IfPC4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS (PTS 6 PRECISION TESTINq!q7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED(MOIYR) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES [:] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATOR L � GATE I,a '}�I IZ.1�LC TSN D7-L �iU11lUGt�� -1-2g _e"i LOCAL AGENCY USE ONLY ( COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# I 1 11 EI I III l / bUko E 10 L_L.LJ CURRENT LOCAL AGENCY FACILITY IDV! APPROVED BY NAME PHONE#WITH AREA CODE 9 / til ' PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ID z CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(3-7-ea) THIS FORM MUST BE ACCOMPANI o A FACILITYISITE APPLICATION, FORM 'A"UNIESSAIll RRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY