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STATE OF CALIFORW WATER RESOURCES CONT& BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑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: 4 s 7Eq__ S'r FARM TANK-YES❑ NO l� Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 A. OWNERS TANK ID# Q B. MANUFACTURED BY: Ltul< C. YEAR INSTALLED I,VJK 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. ��,,, A A. ❑ 1 MOTOR VEHICLE FUEL �2 PETROLEUM B. O- ❑ 1 UNLEADED ❑2 LEADED DIESEL . ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL Ey, PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL 6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL JW9 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FULL,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 ❑ 1 DOUBLEIWAUED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ,�2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 4 STEEL CLAD BERGLASS B.TANK 0 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑810996METHANOLICOMPA BLEFRPORCEO PLASTIC MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL �95 UNKNOWN ❑W OTHER C. INTERIOR ❑ 1 RUBBER LINED ID2 ALKYD LINING F-13 EPDXY UNING ❑4 PHENOLIC UNI NO LINING ❑5 GLASSUNINGUNLINED ❑ 95 UNKNOWN r7 IS UNING ATERIAL COMPATIBLEWTTH IDA METHANOL? YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYET LENE WRAP ❑2 TAR OR ASPHALT ❑�3 VIWLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION F-15 CATHO IC PROTECTION ❑91 NONE iM'�UNKNOWN ❑99 OTHER IV. PIPING INFORMAT19N CIRCLE IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE �" A.SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U 3 GRAVITY A y 99 OTHER u K B. CONSTRUCTION A U SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A(U5 UNKNOWN A U 99 OTHER A U STEEVIRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLADW/FRP A U 9 100%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 P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING 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 IMO/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# JUR SDICTION# AGENCY# FACILITY ID# TANK ID# 3E 0 ® 2 -3 O603 CURRENT LOCAL AGENCY FACII TTY IDX BY NA ZS PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL 6ArE PERMIT EXPIRATION DATE [MHECK# PERMITAMOUNT SURCHARGE AMT. FEE CODE -CEIPTX BY: FORM B(3-7-BB) THIS FORM MUST BE ACCOMPANIED ,1Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY