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-TATE OF CALIFf N&WATER RESOURCES TR OARD FORM 'B': / / UNDERGROUND STORAGE TANK TANK TANK PERMIT APPLICATION INFORMATIONo a; COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ea MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ONE ITEM ❑5 CHANGE OF INFORMATION ❑ 7 p gNENTLY CLO NK ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE FACILITY/SITE NAME WHERE TANK IS INSTALLED: 4-//v S� //N�� 6 TANK REMOVED 6 F /�/� N' -74- FARMTANK j� -YES❑ NO �y I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SOS �� •Q A. OWNERS TANK ID p B. MANUFACTURED BY: C. YEAR INSTALLED W D. TANK CAPACITY IN GALLONS: O If. TANKNTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED, MPLETE ITEM D. Fl A. I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT E]4 OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL j 6 AVIATION GAS ❑5 HAZARDOUS ❑ BO 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 a C.A.S.0 C.A.S.p: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a o A.TYPE OF ❑}'DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER SYSTEM FLY7J( ❑ 95 UNKNOWN 2 NGLEWALLED ❑4 SECONDARY CONTAINMENT [] 99 OTHER B. TANKI STEELPRON ❑2 STAINLESS STEEL El3 FIBERGLASS ❑ 4 STEEL CIAO W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 10096 METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER C. INTERIOR ❑ 1 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑q PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TARORASPHALT ❑ 3 VINYL WRAP PROTECTION ❑4 FIBERGLASS REINFORCED PLASTIC 5 CATHODIC PROTECTION ❑9I NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUEu ,..,. A U 2 PRESSURE A U 3 LINED TY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINA U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STA U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(FIVE) A U 4 FIBERGLASSPWE A U 91 NONE C. MATERIAL A U 5 ALA U 6 CONCRETE A U ] STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GAA U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED, P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 3 7 PRESSURE TESTING P S 94 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED IMO/YR) ' ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN 3.WAS TANK FILLED WITH GALLONS INERT MATERIAL? DYES ❑ 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 1 CO�ODUNTTYEN JURISDICTION N AGENCY M � FACILITY IDN � ©NK ID M CURRENT LOCAL AGENCY FACILITY IDN / APPROVED BY NAME GQG+n�Tq/� PHONE t WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERYIT E%PIRATION DATE CHECK PERMIT AMOUNT SURCHARGE AMT. FEE CODE RE N 8Y: FORM R(6-2966) THIS FORM MUST BE ACCOMPANIED BY A ACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY