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STATE OF CALIFORNIA` WATER RESOURCES CONTROL*ARD FORM B': UNDERGROUND STORAGE TANK PROGRAM4` 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 CL?NO TANK ONE ITEM F-] 2 INTERIM PERMIT F-] 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVEDS FACILITY/SITE NAME WHERE TANK IS INSTALLED: Ina f 4 FARM TANK-YES ❑ IV 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY J A. OWNERS TANK IDM ©� B. MANUFACTURED BY: uK- - A C. YEAR INSTALLED �- D. TANK CAPACITY IN GALLONS: (,/ II. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKEOIJQ151APLETE ITEM D. A. RZ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY UNKNOWN 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.M L11 C A.S.M: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,A D A.TYPE OF1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM w F—]NGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEELIIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE [b:] 7 ALU ❑ 8100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHEN NTNG LINING ❑ 5 GLASS LINING ❑ 6 UNLINED UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WIT D0%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP VI 2 TAR OR ASPHALT ❑ 3 VI ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION E] 5 CATHODIC PROTECTION [:]91 NONE NKNOWN ❑99 OTHER IV. PIPING INFORMAT N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A Wl SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE rzvvm�sA U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U 91 NONE A <95 UNKNOWN U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLWINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U GALVANIZED STEEL A U 95 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 VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P S dE ONICMONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE 95 UNKNOW 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 NAME(PRINTED 8 SIGNATURE) DATE 0 t!! \ lC4 LOCAL AGENCY USE ONLY COUNTY R JURISDICTION M AGENCY R FACILITY ID# TANK ID M D ---3 10o 1 0 CURRENT LOCA AFE LI�I NUMBER UU G APPROVED BY NAME PHONE M WITH AREA CODE IPERMIT PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 1 ;IECKM PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTM \V1nl, FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORMA HAS BEEN FILED�1 DATA PROCESSING COPY