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TATE OF CALIFOR WATER RESOURCES CONT BOARD s•` FORM 'B': UNDERGROUND STORAGE TANK PR GRAM TANK TANK PERMIT APPLICATION INFORMATION m, COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEWPERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑7 PERMANENTLYCL TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE W8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: �, S �c;;�Kl FARM TANK-YES z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY IG A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED K D. TANK CAPACITY IN GALLONS: W 11. 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 R ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 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 FU 7L,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: MI. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A TYPE OF ❑ I DOUBLEWAL ED ❑3 SINGLE WALLED WITHDaERIORUNER ❑95 UNKNOWN SYSTEM ii�2 SINGLE I VALUED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER STEEL/I ION ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRI TE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 1D0%METHANOL COMPATIBLEFRP MATERIAL ❑9 BRON71 ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ 1 RUBBEF LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR 5 GLASS I INING Rr6 UNUNED ❑ 95 UNKNOWN LINING ❑ 1�' ❑ IS LINING AATERIAL COMPATIBLE NTH tIXM METHANOL? ❑YES 0N ❑99 OTHER D. CORROSION ❑ 1 PoLYET ILENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHOi IC PROTECTION 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U 3 GRAVITY A�133 99 OTHER Uo K- B. CONSTRUCTION A W SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 95 UNKNOWN A U 99 OTHER A 0 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C.MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEEL CLAD W/FRP A U 81 OD%METHANOL COMPATIBLE FRP A&GALVANIZED STEEL AO%95 UNKNOWN A U 99 OTHER f V. LEAK DETECTIONS STEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 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 8 95 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 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 NA IE(PRINTED B SIGNATURE) DATE LOCAL AGENCY USE: ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3 � 1313 O� 0D 1I CURRENT LOCAL AGENCY FACILITY ID M A BY ME /Qa PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE \ CHECK# PERMIT AMOUNT -o SURCHARGE AMT. FEE CODE . RECEIPT# BY: FORMS(3-7-80) THIS FORM MUST BE ACCOMPANIE Y A FACILITY/SITE APPLICATION, FORM' SAwdRENT FORMA' HASBEENFILED DATA PROCESSING COPY