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STATE OF CALIFORNIh- WATER RESOURCES CONTRO a OARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM ' TANK TANK PERMIT APPLICATION INFORMATION ego COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE9.TACIIj, ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED S ' w FACILITY/SITE NAME WHERE TANK IS INSTALLED: 61b , Alk & i rJ M7C� A� FARM/TANK-YES❑ NO O I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-$O SPECIFY / � U -4 A. OWNERS TANK IDA I I B. MANUFACTURED BY: 1� C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Q O 11. TANK NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. i MOTOR VEHICLE FUEL [:]2 PETROLEUM C. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL F-13 CHEMICAL PRODUCT F-18.4 OIL 1 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&CA.S.A C A.S.A: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,S,C,S D A.TYPE OF ❑ 1 UBLE WALLED F-13 SINGLE WALLED WITH RTERIOR LINER ❑95 UNKNOWN SYSTEM LEWALIED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER STEBUIRON ❑2 STAINLESS STEEL F--] 3 FIBERGLASS F-] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK 1❑ MATERIAL 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ED8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN [:]99 OTHER F-11 RUBBER LINED El ALKYD LINING ❑ 3 EPDXY LINING �HENOUC LINING C. INTERIOR F-15 GLASS LINING F]6 UNLINED KNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? F]YES F-1NO 99 OTHER D. CORROSION ❑ I POLYETHIENE WRAP ❑2 TAR OR ASPHALT 0/YL WRAP E] 4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:] 5 CATHODIC PROTECTION F]91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMAON 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 91 NONE A U95 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 U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM ACONCRETE A U 7STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 5 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. vSIVISUALCHECK P6/2 INVENTORY RECONCILIATION P $ 3VADOSEWELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURETESTING P 8 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH GALLONS REMAINING IN 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY A JURISDICTION A AGENCY A FACILITY ID A TANK ID A Eal d 101 11 Lf I 3L Io a CURRENT LOCAL AGENCY FACILITY IDN /yamAPPROVED BY NAME PHONE N WITH AREA CODE �._ PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE d �Y CHECK M PERMIT AMOUNT {AURCHARGE AMT. FEE CODE -FCEIPT N BY: q� �j FORM B(6-29-Be) THIS FORM MUST BE ACCOMPANIEB4Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS AR ENT FORMA' HAS BEEN FILED DATA PROCESSING COPY