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STATE OF CALIFORN10 WATER RESOURCES CONTR*BOARD 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 ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 2 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLCpT7M" ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE„ ❑6 TANK REMOVED iS DO FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1.1 IOC S (�, FARM TANK-YES❑ I .A fV I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN p—pSO SPECIFY A. OWNERS TANK ID# o O ,Crc B. MANUFACTURED BY: .(16W ^n_ C. YEAR INSTALLED W V-\ D. TANK CAPACITY IN GALLONS: ��/ II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. &�14 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED L� 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(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 DOUBLEWALED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 RBERGlAS9 ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑6 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL J�225 UNKNOWN ❑99 OTHER ❑ 1 RUBBERUNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOUC LINING C. INTERIOR 5 GLASS LINING ❑6 UNLINED j-UNKNDWN LINING ❑ ❑ IS LINING MATERIAL COMPATIBLE WITH IDD%METHANOL? DYES E] NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2TAR OR ASPHALT ❑ 3VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE KNOWN ❑99 OTHER `IV. PIPING INFORMATIO CLE A IFABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 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 L 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM AU 6 CON A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL �p 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, O(IS P S 1 VISUALCHECK INVENTORY RECONCILI— P S 3 VADOSEWELLS P 8 4 ELECTRONIC MONITOI ° s OAOUND WATER MONITORING WELLS P S 6 PRECISIONTESTIN• P R T PRFS.SIIRFTESTING P S 91 NONE P 8 95 UNKNOWN r 8 o OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANKFILIED 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID 8 .\ TANK ID# aE = Q� 60 O00 CURRENT LOCAL AGENT Y FACILa 100# APPROVED( NAME PHONE#WITH AREA CODE ""... ! N `/'IL �yF, per, ./T PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE p / CHECK# PERMIT AMOUNT RCHARGE AMT. FEE CODE EIPT#is BY: L�j F B(6-29-86) THIS FORM MUST BE ACCOMPANIED NY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY