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STATE OF CALIFORNI WATER RESOURCES CONTRO ARD s , FORM `B': ;s UNDE ROUND STORAGE TANK PRO Al = ` TANK TANK PERMIT APPLICATION INFORMATION =� m COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. L MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION1 ONE ITEM ❑ 7 PERMANENTLY CLOSED TANK El2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED 01� FACILITY/SITE NAME WHERE TANK IS INSTALLED: 0101., L ) �{ "''��I " N cxxA, FARM TANK-YES❑ N�.B� ,� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY W EA. OWNERS TANK ID# ��/ -�tJOC� S O Q B. MANUFACTURED BY: `^'�AR INSTALLED cl kJ D. TANK CAPACITY IN GALLONS: v II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ©MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED �"C1IESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL ( 1 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&C.A.S.# f— C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM tZ2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER B 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING 6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 099 OTHER_ CI D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE T SYSTEM TYPE U0, SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U UD�unWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A NKNOW A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP U UNKNOW A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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 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 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 F3. WAS TANK FILLED WITH r—� SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? [—]YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MYKNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# b 10 1 :al�:mon 0 Lo Lij I ENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME L � w PHONE#WITH AREA CODE T NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE # PERMIT AMOUNT SURCHARGE AMT. FEE CODE J RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIEM A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CWRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY