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STATE OF CALIFOF0, WATER RESOURCES COOARD FORM 'B': UN ERGROUND STORAGE TANK FyRbGRAM ' TANK TANK PERMIT APPLICATION INFORMATION ® N COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. `7 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 'SCHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED ,C' 2 L N FACILITY/SITE NAME WHERE TANK IS INSTALLED: 0J n' YG ,t! �'1OCk-IC17 FARM TANK-YES❑ NO ilk I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N A. OWNERS TANK IDR o�, N I ' ��Q � B. MANUFACTURED BY: unlcnpkJY1 IV' C. YEAR INSTALLED n k YIGW V-\ D. TANK CAPACITY IN GALLONS: 5 11. TANK CONTENTS IF(A.1),IS 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 q?i�PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF I HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM NGLEWALIED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 SFEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL E:4�NKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBERUNED ❑2 ALXYO LINING ❑3 EPDXYLINING ❑4 PHENOLIC UNING LINING ❑5 GLASS LINING ❑6 UNLINED Ej4TTNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TARORASPHALT ❑3 VINYLWRAP ❑ 4 FIBERGLASSREINFORCED PLASTIC PROTECTION ❑'@ CATHODIC PROTECTIQN ❑ 91 NONE UNKNOWN ❑99 OTHER IV. .PIPING INFORMATION IRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A(U)t)tSUCTIOV A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 Up 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_)6 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 5 ALUMINUM AU B A U 7 STEELCLADW/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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 8 1 VISUAL CHECK ®8 2 INVENTORY RECONCILIATION P B 3 VADOBE WELLS P 8 4 ELECTRONIC MONITOP P. 6 5 GROUNDWATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN Y S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L 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 B SIGNATURE) DATE LOCAL AGENCY USE ONLY 10E COUNTYR JURISDICTION R AGENCYR FACILITY ID# TANK ID# RRENT LOCAL AGENCY FACILITY ID N '' APPROVEO-BY -- --- "` 'PHONE N WITH AREA CODE ENGIN � 9 o RMITNUMBER -' PERMITAPPROVAL DATE'- PERMIT EXPIRATION DATE I CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY FORM STB-z9-EB) THIS FORM MUST BE ACCOMPANI FACILITY/SITE APPLICATION, FORM 'A',UNLESS A L..HRENT FORMA HAS BEEN FILED DATA PROCESSING COPY