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STATE OF CALIFORNIPO WATER RESOURCES CONTROL' ARD 'E �s FORM `B': UNDER ROUND STORAGE TANK PRO AM mT TANK TANK PERMIT APPLICATION INFORMATION ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK, r'' 7— 1cl MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERWT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEQ TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED' y, tln.. FARM TANK-YES El NO W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY (�I A. OWNERS TANK ID# LOW B. MANUFACTURED BY: 00 C. YEAR INSTALLED My q 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 PETROLEUM B. C. Ol UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL �RODUCT ❑ 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.# &1 C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM V2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FlBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑'6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ C. INTERIOR 1 RUBBER LINED El2 ALKYD LINING F—] 3 EPDXY LINING E] 4 PHENOLIC LINING �J LINING 5 GLASS❑ LINING MATERIAL LINED [:]00%METHANOL? YES NO 95 UNKNOWN SLIN G 99 OTHER U6 K D. CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TAA OR ASPHALT ❑ 3 PNYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION CATHODIC PROTECTION ❑ 91 NONE MR UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABO GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A YN 1 SUCTION A 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 A U 95 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 CLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 61 5 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 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 4 P S 6 PRECISION TESTING-K 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 LAST USED(MG/YR) 2. ESTIMATED QUANTI OF 3, WAS TA K FILLED WITH SU �!tBSTANCE REM�1 I G IN GALLONS INERT ERIAL? ❑YES F] 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# [all I I ] o 1 11016111 :3 6, _ b O To CURRENT LOCAL AGENCY FACILITY IDK APPROVED BY 4AMPHONE#WITH AREA CODE 7- 11 `L 111-Ju PERMIT NUMBER PERMIT APPROVAL ATE PERMIT EXPIRATION DATE CHECK#F PERMIT AMOUNT SURCHARGE AM FEE CODE RECEIPT p BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANI 1. Y A FACILITY/SITE APPLICATION, FORM `A',UNLESS RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY