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STATE OF CALIFORNJJ WATER RESOURCES CONT BOARD FORM 'B': UND GROUND STORAGE TANK PRRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. m b MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EJ5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: ' QQ 4flA FARM TANK-YES❑ NO-®- 7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 00 A. OWNERS TANK IDA B. MANUFACTURED BY: Un C. YEAR INSTALLED41-44 D. TANK CAPACITY IN GALLONS: /n(I% 00r) 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. FI MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED �LEADED ❑3 DIESEL 3 CHEMICAL PRODUCT ❑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 8 C.A.S.# C.A.S.A: OIL TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM 521 SINGLE WAU.ED ❑4 SECONDARY CONTAINMENT ❑99 OTHER I STEEURON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCEDPLXSTIC B. TANK 5 CONCRETE 6 POLYMNYL CHLORIDE 7 ALUMINUM MATERIAL ❑ ❑ ❑B 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER UNED ❑2 ALKYOUNING ❑3 EPDXY UNING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED tR95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 F18ERGLASS REINFORCEDPLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE R-95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A ml SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U B CONCRETE A U 7 STEELCLADW/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 095 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 Q�S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS O P®6 PRECISION TESTING P S 7 PRESSURE TE STING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MON#) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? [:]YES E] 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 m JURISDICTION � AGENCY AFACILI�A � � TANK ID A Q 3 1 © C CURRENT LOCAL AG CY FACILITY IDA APPROVED BY NAME PHONE A WITH AREA CODE PERMIT NUMBER PERMITAPPROVALDATE PERMIT P A IN DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# gy; FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIEL.n A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A „ ENT FORM'A' NAS BEEN FILED .::ATA PROCESSING COPY