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STATE OF CALIFORh WATER RESOURCES CONT�BOARD FORM 'B': UND RGROUND STORAGE TANK PR GRAM TANKTANK PERMIT APPLICATION INFORMATION H TANK. Z COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACo MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED ANK ONE ITEM ❑2 INTERIM PERMIT F-14 AMENDED PERMIT CC ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED IV FACILITY/SITE NAME WHERE TANK IS INSTALLED: 2, S. e c ci-�f�'lQ FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I T CD A. OWNERS TANK ID# Gl U -L I" , B. MANUFACTURED BY: (✓ C. YEAR INSTALLED A lk,1 - D. TANK CAPACITY IN GALLONS: Is C3 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 PRODUCT Cf:�ja OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN tat WASTE ❑ 7 METHANOL F45eg OTHER(DESCRIBE IN ITEM D,BELOW) 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF (L 4-, ' C.A.S.#: HAZARDOUS SUBSTANCE STORED 8 C.A.S.# lil.J III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF ❑1 DOUBLE WALLED ❑3 SINGLEWALU OWITHE%TERIOR LINER UNKNOWN SYSTEM ❑2 SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEELPRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER UNEO ❑2 ALKYO LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLICUNING C. INTERIOR ❑ 5 GLASS LINING F-1UNK 6 UNLINED FE-95 NOWN LINING (A ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO �ER D. CORROSION ❑ 1 POLYETHIENEWRAP ❑2TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE L�KNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPEA U 1 SUCTION A U 2 PRESSURE A U IGRAVITY 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 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6C A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 1�> NKNOWN 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 T 21 RY RECONCILIATI P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING 7 TING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# �rJURISDICTION# I AGENCY# FACILITY ID# TANK ID# b vFi f) D b o CURRENT LOCAL AGENCY FACILITYY ID X� Cl APPROVED B�EI ' PHONE#WITH AREA CODE OC PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT AMOUNT URCHARGE AMT. FEE CODE EIPT X BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY