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STATE OF CALIFORNIA* WATER RESOURCES CONTROLWRD g•�;.°;=M, FORM B': UNDERGROUND STORAGE TANK PROGRAM loll TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM I !/I ` INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: Y-3-7 t^ I%e, FARM TANK—YES❑ NO Er 1. TANK DESCRIPTION COMPLETE ALL ITEMS—IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID 0 tx_ B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: o 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 DIESEL00 ❑ 3 CHEMICAL PRODUCT [�IL ❑ 1PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS [:] 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ©-1�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.0 C.A.S.0: xII I. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 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 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C. INTERIOR F-1I RUBBER LINED ❑2 ALKYD LINING F__] 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ S GLASS LINING ❑6 UNLINED 95 UNKNOWN ® IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑ 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 PRESSURE A03 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED d U 3 LINED TRENCH A<0 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 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A/-'0 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 4D 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 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1 ESTIMATED DATE LAST USED(MQlYR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH /(,/ SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? Ll YES L] NO ,Y 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# TANK ID# 6,101 / I / I F I /I L01 6101l CURRENT LOCAL AGENCY FACILITY ID# APPROVER BY A E PHONE#WITH AREA CODE U PERMIT NUMBER PERMIT,A�PPPROVAAL�DATE PERMIT EXPIRATION DATE / U 9 CHECK M PERMIT AMOUNT SURCHAR E kMT. FEE CODE �RlllEIPT# BY: 1°' RM B(3-7-66) THIS FORM MUST BE ACCOMPANAEL I A FACILITY/SITE APPLICATION, FORM `A',UNLESS AL� RENT FORMA" HAS BEEN FILED DATA PROCESSING COPY