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STATE OF CALIFORNIfa WATER RESOURCES CONTROOARD FORM 'B': UNDE GROUND STORAGE TANK PRO AM TANK TANK PERMIT APPLICATION INFORMATION m COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLYVINTERIM PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: �,3 S $7SAt,,FARM TANK-YES❑ NO EZTZ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 A. OWNERS TANK ID# k B. MANUFACTURED BY: C.YEAR INSTALLED I go D. TANK CAPACITY IN GALLONS: QD w II. TAIL,60NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,SAIMPLETE ITEM D. 0 A. i MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB�. / C 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL IILJ , 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.#: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D I: A.TYPE OF ❑ DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN I!2 SYSTEM V2 SI GLE WALLED ❑4 SECONDARY T14TAINMENT [:j 99 OTHER 1 STEELARON ❑2 STAINLESSkEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑ 6 POLYVINYLCHLORIDE F-] 7 ALUMINUM El8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR IL=✓J�/ I RUBBER LINED ❑2 ALKYDUNING ❑ 3 EPDXY LINING ' <f}IENOUC LINING LINING ❑5 GLASS LINING �fi UNLINED 95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLRIE WRAP ❑2 TARORASPHALT 3)MISYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE Lg 95 UNKNOWN ❑99 OTHER IV. PIPING INFORM!4N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE IPVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U UNKNOWN A U 99 OTHER V. LEAK DETECTION SY TEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. S- 1 VISUAL CHECK S INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P 6 PRECISION TESTING P S 7 PRESSURE TESTING 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(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN OALLONe INERT MATERIAL? DYES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID M TANK ID# - = oc /= 14:9 CURRENT LOCAL AGENCY FACILITY IDX APPROVED BY NAME P HE N WITH AREA CODE s- 3 � PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMITAMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: FORMB(3-7-88) THIS FORM MUST BE ACCOMPIWIDBY A FACILITY/SITE APPLICATION, FORM'A!,UNLEWURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY