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STATE OF CALIFORNO WATER RESOURCES CONTRjBOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z 10 MARK ONLY ❑ I 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 -��ANK REMOVED O W FACILITY/SITE NAME WHERE TANK IS INSTALLED: ma;n FARM TANK-YES❑ NO IV I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-$O SPECIFY („ A. OWNERS TANK ID# -n 0-0tB. MANUFACTURED BY: C. YEAR INSTALLED LQ10() I D. TANK CAPACITY IN GALLONS: �w II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ I UNLEADEDFADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCR)BE 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 7 A. TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER En..95 UNKNOWN :f SYSTEM ❑2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLADW/FIBERGLASSREINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEELS UNKNOWN ❑ 99 OTHER C. INTERIOR F-11 RUBBER LINED ❑2 ALKYDUNING F-13 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED 9-5 ❑ ISLINING MATERIAL COMPATIBLE WITH 10D%METHANOL? ❑YES ❑-NO ��'99"OTHER Vl D. CORROSION ❑ 1 POLYEHLENEWRAP ❑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 57 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 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 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U ,9""ALUMINUM A '6CONCRETE A U 7STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP I A U 9 GALVANIZEDSTEEL A UUNKNOWN 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 S IVISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8' 3VADOSE WELLS S 4 ELECTRONIC MONITOR P 8 5 G�f^i6uNp WATER MONITORING WELLS P 5 6 PRECISION TESTING P 5 7 PRESSURETESTING P 8 91 NONE P 95 UNKNOWN P S 99/ETHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO GALLONS 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) WT� i,N 1 LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 01 ol 01 1 CURRENT LOCAL AGENCY FACILITY I N ^ I � APPROVED BY NAME - O PHONE#WITH AREA CODE PERMIT NUMBER 1yJ` PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMITAMOUNT SURCHARGE AMT. FEE CODE ECE IPT# BY: UTO IL/FORM 8(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACIISITE APPLICATION, FORM `A',UNLESS A CURRENT FORMA' HAS BEEN FILED j ATA PROCESSING COPY