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STATE OF CALIFORN& WATER RESOURCES CONTR�OARD FORM `B': UNDERGROUND STORAGE TANK'PR AM TANK TANK PERMIT APPLICATION INFORMATION W' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z Io MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE [ 6 NK REMOVED Qq IV FACILITY/SITE NAME WHERE TANK IS INSTALLED: m I !Lr FARM TANK-YES❑ NO 1 -111. 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I O A. OWNERS TANK ID# ( LL- (- B. MANUFACTURED BY: C.YEAR INSTALLED RJ— D. TANK CAPACITY IN GALLONS: L4 UO U II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. E2'1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. O ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑4 OIL �f'l"RODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HA Z4 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL, OF HAZARDOUS SUBSTANCE STORED 8,C.A.S. (� C.A.S.W III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,8 D A TYPE OF ❑ 1 DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER El95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHm ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYL CHLONDE ❑ 7 ALUMINUM ❑B 10096 METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEELUNKNOWN ❑99 OTHER F-] I RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXY UNING ❑4 PHENOLIC UNING C.LINING R ❑ 5 GLASS LINING ❑6 UNLINED -E]-9-UNKNOWN �} E] IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES [:] �NO OTRER u AL D. CORROSION ❑ I POLYEfHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 RBERGLASSREINFORCEDPLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONEUNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A 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(U!IF 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 A U 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 ALUMINUM6 CONCRETE A U 7 STEELCLADW/FRP A U 81 OD%METHANOL COMPATIBLE FRP A A U 9 GALVANIZEDSTEEL U 5 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 5 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSEWELL 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED IMO/VR 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH GALLONS 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 7I it = = 0 ( � ` - C� - CURRENT LOCAL AGENCY FACILITY ID M E p APPROVED Y-VlA� `-( PHONE#WITH AREA CODE PERMIT NUMBER I/ I r,^' PERMIT APPROVAL DATE �LPERMIT EXPIRATION DATE CHECK M PERMIT AMOUNT RURCHARGE AMT. FEE CODE aEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORMA' HAS BEEN FILED ::ATA PROCESSING COPY .i�-"