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STATE OF CALIFORNI40 WATER RESOURCES CONTRO60ARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1,NEWPERMIT ❑ 3 RENEWALPERMITWA ANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM Lkr2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVER' V FACILITY/SITE NAME WHERE TANK IS INSTALLED: q9N FARM TANK-YES❑ NO Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 A. OWNERS TANK ID# 0-- / B. MANUFACTURED BY: U C. YEAR INSTALLED lwwD. TANK CAPACITY IN GALLONS: ls-�)o S 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. O A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL 3 CHEMICAL PRODUCT IL ❑ 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWNASTE ❑7 METHANOL ❑�Ell(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF � A- � HAZARDOUS SUBSTANCE STORED&C.A.S.# �I1G U� C.A.S.#: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINERNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PL,AST.0 B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 AWMI ❑ 8100%METHANOL COMPAT18LEFAP MATERIAL ❑9 BRONZE 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER C. INTERIOR F-11 RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXY LINING ❑ 4 PHENOLIC UNING LINING ❑5 GLASS LINING ❑fi UNLINEDNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TARORASPHALT ❑3 VINYL ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMA N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A W SUCTION A U 2 PRESSURE A GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A(635 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 U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE ERP A U 9 GALVANIZED STEEL <A5 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. P 8 1 VISUAL CHECK os 2 INVENTORY RECONCILIATION- P S 3 VADOSE WELLS P',S 4,ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS ll I 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 VIA / GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? E]YES El NO / THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT NAME(PRINTED&SIG URE) DATE LOCAL AGENCY USE O LY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# ol o I o c) o CURRENT LOCAL ENCY FACILITY ID# APPROVED. YNAMEo PHONE#WITH AREA CODE AT PERMIT NUMBER LLSS PERMIT APPROVAL DATE dy PERaaM�MIIT EXPIRATION DATE [CHiPERMIT AMOUNT SURCHARGEAMT. FEE CODE REC CK# EIPTN BY: FORM B(3-7-SS) THIS FORM MUST BE ACCOMPANIEU.,Y A FACILITY/SITE APPLICATION, FOR M 'A',UNLESS A NRENT FORM'A. HAS BEEN FILED DATA PROCESSING COPY