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STATE OF CALIFORNIO WATER RESOURCES CONTROI )ARD FORM 'B': UNDERIOROUND STORAGE TANK PROIVAM TANK TANK PERMIT APPLICATION INFORMATION .�-o-' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z Io MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PF.RMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED D 9 FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK C}+v CN -YES❑ NO N N I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID N d 41 CTURED BY (' PLf C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 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, ' ❑ 1 UNLEADED ❑ 2 LEADED E:] 3 DIESEL F__] 3 CHEMICAL PRODUCT '�4 OIL r_11 PRODUCT E]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&C.AS.N m_ C.A.S.R: (/ III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A.TYPE OF ❑ 1 OUBLE WALLED F—] 3 SINGLE WALLED WITH EXTERIOR LINER E] 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER I STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8100%METHANOL COMPATIBLE FOP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 A DLINING El EPDXY LINING F-14 PHENOLIC LINING LINING ❑ 5 GLASS LINING 6 UNLINED ❑ 5 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 9999 OTHER �^'-"N"'• D. CORROSION ❑ 1 POLYETHLENEWRAP AR OR ASPHALT F-13 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UND OUND,BOTH IF APPLICABLE A SYSTEM TYPE A SUCTION A U 2 PRESSURE U GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH 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 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 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. �. 1C P B 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING 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 TA K FILLED WITH p$411 SUBSTANC AINING IN INE TRIAL? E]YES ❑ NO A p GALLONS 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 N JURISDICTION N AGENCY R FACILITY ID N (' TANK ID N U 1 0 1 Ll Lf b d CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY JAME If PHONE N WITH AREA CODE PFAMIT NUMBER PERMIT APPROVAL DATE PERMIt EXPIRATION DATE CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORMB(6-29-88) THIS FORM MUST BE ACCOMPANIEOVP'A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A ZMENT FORM'R HASBEENFILED DATA PROCESSING COPY"