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STATE OF CALIFORNIf WATER RESOURCESCONTROARD FORM 'B': UNDERGROUND STORAGE TANK PR0 AM TANK /�� TANK PERMIT APPLICATION INFORMATION m C/ COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. _ Z' 10 MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT EvCHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDJANK ONE ITEM Q 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 2 S 7k FARM TANK-YES❑ NO W 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY ! —4 h-& A. OWNERS TANK IDN $ B. MANUFACTURED BY: r( - W C. YEAR INSTALLED ID./TANK CAPACITY IN GA LONS: IL TANK 9ONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A, ),IS NOT MARKED, MPLETE ITEM D. A. DZI MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. 1 UNLEADED ❑ 2 LEADED E]3 DIESEL ❑ 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.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM 2 NGLE WALLED ❑4SECONDARY CONTAINMENT ❑ 99 OTHER vi 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEELCLADW/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C.INTERIOR F-11 RUBBER LINED ❑ KYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING 6 UNLINED 95 UNKNOWN /� ❑ IS LINING MATERIAL COMPATIBLE WI 0D%METHANOL? ❑YES 0 N 2<OTHER uA D. CORROSION ❑ 1 POLYETHLENEWRAP 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 An i SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 9/ NONE p 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 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 A U 5 ALUMINUM A6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A UU 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 Q S I INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS (1 S 6 PRECISION TESTING P S ' PRESSURE TESTING P S 91 NONE P 8 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? ❑YES E] NO 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# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 10 1010 -2- 1010101 1010101/ ] CURRENT LOCAL AGENCY F�A9y1LLIITY ID# APPROVED BY NAME PHONE#WITH AREA CODE 4571N--o l 2i Z /S $ PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FoaM e Is-z9 3eI THIS FORM MUST BE ACCOM, TO BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS...:URRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY