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STATE OF CALIFORN& WATER RESOURCESCONTROARD FORM `B': UNDERGROUND STORAGE TANK PR RAM TANK TANK PERMIT APPLICATION INFORMATION ` am COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION n 7yERMANENTLY CLgN ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE rum- 88 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: / FARM TANK-YES❑ •Q I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# a- B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Go II. TANK CqNTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. O! A_ MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. ❑ 1 UNLEADED [-] 2 LEADED DIESEL F-13 CHEMICAL PRODUCT [:] B.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.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM NLY IN BOX A,B,C,A D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WA ED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ 4 SECONDARY NTAINMEM ❑99 OTHER ❑ 1 STEEL/IRON ❑25TAINLESS STEE ❑ 3 FIBERGLASS ❑ 457EEL CLAD WIFIBERGIASS REINFORCED PLASTIC B.MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORI ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED [E::] 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑ NO ❑ 990THER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAO OR ASPHALT ❑ 3 INYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑ 95 KNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDE GROUND,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 i SINGLE WALLED A U 2 DOUBLE WALLED A U LINEDTRENCH 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 OLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U S ALUMINUM A U 6 CONCRETE A U 7 S EEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 O HER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDA Y,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P S ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S R UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN G LLONS INERT MATERIAL? ❑YES 0 N THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST F MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# I 10191 / 1316131 000 CURRENT LOCAL ENCY FACILITY ID APPROVED BY N E e PHONE#WITH AREA CODE � PERMITN ER PERMIT APPROVAL DATE ERMITAXPIRATION DATE CHECKM PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIEa, A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY J