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STATE OF CALIFORNO WATER RESOURCES CONTROARD FORM 'B': UND GROUND STORAGE TANK PR RAM TANK ATANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 2151CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED/TANK ONE ITEM ❑2 INTERIM PERMIT [:]4 AMENDED PERMIT 1:16 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED IS FACILITY/SITE NAME WHERE TANK IS INSTALLED: ,Y� �- M FARM TANK-YES❑ NO ❑ Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY i© A. OWNERS TANK ID# AAf.i B. MANUFACTURED BY: ai- C. YEAR INSTALLED N D. TANK CAPACITY IN GALLONS: U a II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL F-12 PETROLEUM B. C. ❑ 1 UNLEADED LEADED ❑ 3 DIESEL F-] 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS I. ❑5 HAZARDOUS ❑ 80 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&C.A.S.If �(/ C.A.S.#: a .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ I DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXFERIOR LINER 5UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7ALUMINUM MATERIAL ❑8 100%METHANOL COMPATIBLE FAP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 5 UNKNOWN ❑ 99 OTHER C. INTERIOR F-11 RUBBER LINED E] 2 ALKYD UNING ❑ 3 EPDXY LINING E] 4 PH UCLINING LINING ❑5 GLASS LINING ❑6 UNUNED F2,T 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3 VIW RAP ❑4FI8ERGLA9S REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑ 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 99 OTHER B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 95 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A lL 6 CONCRETE A U 7 STEELCLADW/FRP A U R 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A ep 95 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. 91- 1 P81 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSEWELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURETESTING P S91 NONE' P S 95 UNKNOWN P S 99 OTHER . INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED,( 0/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH Af.I� GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? [:]YES E] NO �V THIS FORM HAS BEEN 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# FACILITY ID# TANK ID# J = = IUO 1 R- 3 010 1 v Il [PELRMITNUMBER AL AGENCY FACILITY ID N APPROVED BY NA E PHONE It WITH AREA CODE �S 9 � � PERMIT APPROVAL DATE PER TEXPIRAT NDATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE EIPTN SY: FORMB(3-7-8B) THIS FORM MUST BE ACCOMPANI YAFACILITY/SITEAPPLICATION, FORM `A',UNLE RRENT FORMA' HASBEENFILED DATA PROCESSING COPY