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STATE OF CALIFORNIA WATER RESOURCES CONTR 0ARD FORM `B': UNDERGROUND STORAGE TANK PRO URAM TANKTANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TA ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED w FACILITY/SITE NAME WHERE TANK IS INSTALLED: �, FARM TANK-YES❑ NO W IV I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A A. OWNERS TANK ID# a-- B. MANUFACTURED BY: (2 C. YEAR INSTALLED Jam,l< 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. I I A. F-] 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 FUELtt� 6 AVIATION G4 ❑ 5 HAZARDOUS ❑80 EMPTY UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL. 1:199 OTHERRIIN IT D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF I HAZARDOUS SUBSTANCE STORED&C A.S.# CAS.#. Y� 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A. TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINEA UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑'1:STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED P TIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL [:] 9 BRONZE ❑ 10 GALVANIZEDSTEEL [24UNKNOWN E] 99 OTHER ./ [:] 1 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING E] 4 PHENOLIC LINING { / G. INTERIOR ❑5 GLASSLINING ❑6 UNLINED UNKNOWN ❑ IS UNING MATERIALCOMPATIBLE WITH 100%METHANOL? ❑YES ❑ NOOTHER /\ D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALTn 3 VII�(L WRAP ❑4 FIBERGLASS 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 91 NONE A U 5 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 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE IPVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD WEEP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL Ao 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 S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P 8 91 NONE P S 5 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 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 S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 101012131ekt7l 1610051 CURRENT CY EAGLET IDS APPROVED YNAME�� PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE P ISM EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE I fflECEIPT# BY: 16 1AAh FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIE BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS AlWRENT FORMA' HAS BEEN FILED S DATA PROCESSING COPY