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STATE OF CALIFORPoh WATER RESOURCES CONTOARD FORM `B': UNDE GROUND STORAGE TANK PR GRAMa TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOW" )NFORMATION FOR EACH TANK. z MARK ONLY F-11 NEW PERMIT F-] 3 RENEWAL PERMIT J a CHANGE OF INFORMATION J7/ MANENTLY G OSONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED ,f} v N FACILITY/SITE NAME WHERE TANK IS INSTALLED: 0kV FARM TANK-YES❑ NO � I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# 10 B. MANUFACTURED BY: C. YEAR INSTALLED Of—7 D. TANK CAPACITY IN GALLONS, II. TANK RONTENTS 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 ❑ 60 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.9 C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 BLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ®2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGLASS REINFOPCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ S 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER F-11 RUBBER LINED ❑ 2 ALKYD LINING El EPDXY LINING ❑ 4 P OLIC LINING C. INTERIOR LINING F--] 5 GLASS LINING El5 6 UNLINED UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER 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 CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A CU7 PRESSURE A U 3 GRAVITY A U 91 NONE A 95 UNKNOWN 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 U 5 UNKNOWN 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 A6 CONCRETE A U 7 STEEL CLAD W 1FRP A U B 10095 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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. S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTI NG S 7 PRESSURE TESTI NG 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 GALLONS INERT MATERIAL? F—]YES E] NO THIS FOPM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TPUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# Eju I I --1:1 El I I lif) d � olz�ll JCHECKO RENT LOCAL AGENCY CILITTY ID# APPROVED BY NAME PHONE N WITH AREA CODE IT NUMBER PERMIT APPR Y. LAT PERMIT EXPIRATION DATE Z PERMIT AMOUNT SURCHARGE AMT. E CODE RECEIPT N BY: FORM B(6-29-65) THIS FORM MUST BE ACCOMPAN. A FACILITYISITE APPLICATION, FORM 'A',UNLESS RENT FORMA' HAS BEEN FILED _ DATA PROCESSING COPY