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STATE OF CALIFORNI& WATER RESOURCES CONTROARD FORM 'B': UNDE GROUND STORAGE TANK PRO AM ; w TANKTANK PERMIT APPLICATION INFORMATION ' A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. �" Q MARK ONLY i NEWPERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION COMPLETE ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT '' ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED U FACILITY/SITE NAME WHERE TANK IS INSTALLED: W t.�n,n.i-v/meq FARM TANK-YES❑ NO LnW I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY ' co A. OWNERS TANK ID# B. MANUFACTURED BY: ( K� C. YEAR INSTALLED `g D. TANK CAPACITY IN GALLONS: Dd 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 ❑ 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 FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED& III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,A D A TYPE OF ❑ 1 UBLEWALLED F-13 SINGLEWALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM r 2 SI GLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ❑ 2 STAINLESSSTEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 100%MEFHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER ❑ 1 RUBBER UNED F 2 AI,XND LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING C. LININ INTERIOR ❑5 GLASS LINING L+�i u/UNLINED ❑ 95 UNKNOWN LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 990THER D.CORROSION ❑ 1 POLYEFHLENEWRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION U PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION U 1 SINGLE WALLED A 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE 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 A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEELCLADW/FRP A U &100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL I U 5 UNKNOWN A U 99 OTHER �. LEAK DETECTION STEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. ` P VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS [:! P S PRECISION TESTING P 4 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIM TED DATE LAST USED(MO/YR) 2. ESTIMATE QUANTITY OF 3.WAS TA KFILLEDWITH SUB TA MAIMING IN INERT A RIAL? ❑YES ❑ NO GALLONS TW FORM HAS BEEN COMPLETED UNDER PENALTY O PERJURY,AND TO THE BEST OF MY KNOWLE OE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# IOL5 1 c Dd CURRENT LOCAL AGENCY FACILITY ID 0 APPROV BY N ME PHONE 0 WITH AREA CODE � A)� bit �� PERMIT NUMBER PER TAPPROVALDATE PERMIT EXPIRATION DATE CHECKp PERMIT AMOUNT SURCHARCEA FEE CODE RECEIPTp BY: FORMBI6-29-881 THIS FORM MUST BE ACCOMPANIED YA FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RRENT FORM'A' HASBEENFILED DATA PROCESSING COPY