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r,. _ . STATE OF CALIFORNIO WATER RESOURCES CONTR*OARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION (az COME A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 110 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑7 PER NENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE - ANK REMOVED E5 97 N FACILITY/SITE NAME WHERE TANK IS INSTALLED: ,j l/ia�i FARM TANK-YES❑ NO Ll 'thk I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY O A. OWNERS TANK ID# B. MANUFACTURED BY: t C. YEAR INSTALLED 'A i"'•" D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),ISI MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL / ❑6 AVtATION,GAS ❑5 HAZARDOUS ❑ 80 EM PN ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTH�R)DESCRIBE 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 A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM ❑2 SINGLEWALLED ❑ 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 POLYVINY�CHLORIDE ❑ 7 ALUMINUM ❑8 160%METHANOLC0MPATIBLEFRP MATERIAL ❑9 BRONZE .❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY U G 4 PHENOUG LINING C. INTERIOR LINING F-15 GLASS LINING F--] 6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIA COMPATIBLE WITH IDO%MEfHANOL? YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP 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 U 1 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 A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 6ALUMINUM A U 6CONCRETE A U ] STEEL CLAD W/FRP A U 8108%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A- U 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. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P IS 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/VR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS 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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY -- COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 0 6) 1 -6a [-3 L CURRENT LOCAL AGENCY FACILITY ID K APPROVED BY NAME PHONE N WITH AREA CODE 3 / lrl PERMIT NU BER IPERMIT APPROVAL DATE P RM EXPIRAirbATiE CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: - FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIE IfY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A LUHRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY