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TATE OF CALIFORNIO WATER RESOURCES CONTR*OARD \ / ORM `B': UNDERGROUND STORAGE TANK PROGRAM ANK TANK PERMIT APPLICATION INFORMATION o, COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY /CLOSED TANK ONE ITEM If ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE a FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I A. OWNERS TANK ID B. MANUFACTURED BY: G t% C.YEAR INSTALLE 41&1 D. TANK CAPACITY IN GALLONS: UU O II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. N A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUMC. ❑ 1 UNLEADED ❑ 2 LEADED DIESEL ❑ 3 CHEMICAL PRODUCT F-14 OIL B. 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL E]6 AVIATION GAS ❑5 HAZARDOUS E] 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME A HAZARDOUS SUBSTANCE STORED&C .S. �(� �- C.A.S. y All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,S O A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNE UNKNOWN SYSTE �� 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER Ei1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK �� F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8100%METHANOL COMPATIBLE FRP NATE ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIORD❑ I RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING 4 P UCUNING LINING F-15 GLASS LINING ❑6 UNUNED95 UNKNOWN ISUNING MATERIAL COMPATIBLE WITH IOD%METHANO YES NO ❑99 OTHER D. COAROSICNgo 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION EjWNONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFO ATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTIO A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH (U')95 UNKNOWN A U 99 OTHER A U i STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A(FJ5 UNKNOWN A U 99 OTHER LZ LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLEo. r/� P 5 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 3 4 ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS I✓✓[ I P S B PRECISION TESTING P S 7 PRESSURETESTING ( S 91 NONE- P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. STIMATED DATE LAST USED(MO/YR) ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH . /� UBSTANCE REMAINING IN INERT MATERIAL? E]YES L] NO /V GALLONS THIS FORM HAS BfEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# Zoo FACILITY ID# TANK ID# a-11121 s = = 0O l �{ �i / I oo o ENT LOCALAGENCYF GILITY IDN OVED BY NAME PHONEp WITH AREA CODE �� 7 PERMIT NUMBER PERMIT APPROVAL DATE AERMIT EXPIyfAlRON DATE CHI PERMIT AMOUNTSURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIE BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A WRRENT FORMA HAS BEEN FILED DATA PROCESSING COPY