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STATE OF CALIFORNIA WATER RESOURCESCONTROIOARD °` . FORM 'B': UND ROUND STORAGE TANK PRO AMS TANK TANK PERMIT APPLICATION INFORMATION "m �' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - _ z MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑�7 PERMANENTLY CLOSED TANK 10 ONE ITEM F-12 INTERIM PERMIT [-]4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE LJ°TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: L4 I I OSA M 1 is MOLr n-R CD__ FARM TANK-YES❑ NO Ea ,A I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: Y1 IL C. YEAR INSTALLED LtA k I D. TANK CAPACITOF. N GALLONS: Q 11. 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. C. ❑ 1 UNLEADED ❑2 L ED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL L� PRODUCT ❑4 GASAHOL FUEL R f AVIATION GAS - ❑5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL 99 OTHER(D SC IBE 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,A D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXFERIOR LINER ,\\ ❑95 UNKNOWN SYSTEM [Z2 SINGLEWAUED ❑4.SECONDARYCONTAINMENT 99 OTHER ❑ 1 STEELPRON ❑2 SFAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLEFRP MATERIAL ❑ I<�9 BRONZE ❑ 10 GALVANIZED STEEL ✓1 '"UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXY UNING ❑4 PHENOLICUNING C. INTERIOR IN NG R ❑5 GLASS LINING ❑6 UNLINED UNKNOWN OAK ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES [:] NO OTHER V 1� D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE Ela-SS UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A UNKNOWN A U 99 OTHER S.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A© NKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SIPSkMUST BE CIRCLED. P 8 1 VISUAL CHECK P 6 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 6 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P B UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OFGALLONS 3.WAS TANK FILLEDS#RH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES [-] 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# 39 I ooa3o � I I o I vv I I L CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE _TT_Y L{ 1 . 2-V G C IA..) PERMIT NUMBER PERMIT APPROVAL DATE PERMIT E%PIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT k BY. i FORM 9(6-29-63) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY