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-, �,,. -'T.;T'R..m.Fp.Y. _.-�'�R'-.•Y:.e.,.�.-FWTF?-'7p'o�.�._�.C'Fkr'S,y-�.�1.�.��. .,,s,•.,�+�� F, 1,y_.Y�......�,-pr.rv..TRYP� "�''9 STATE OF CALIFORNI WATER RESOURCES CONTRO ARD FORM `B'. UNDE ROUND STORAGE TANK PRO AM m TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INF" ATION FOR EACH TANK. F9 N.P MARK ONLY F-] 1 NEW PERMIT F-] 3 RENEWAL PERMIT .ANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM INTERIM PERMIT ❑ 4 AMENDED PERMIT n R TEMPORARY TANK CLOSURE ❑8 TANK REMOVED ! !1 J1 FACILITY/SITE NAME WHERE TANK IS INSTALLED: / r / FARM TANK-YES❑ NO - I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED 41w1elD. TANK CAPACITY IN GALLONS: d CIO II. TANK SqNTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,CO ETE ITEM D. C" A 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM �Tl C. 1 UNLEADED ❑ 2 LEADED E] 3 DIESEL F--] 3 CHEMICAL PRODUCT F-] 4 OIL PROI)UCT ❑ 4 GASAHCL ❑ 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 J HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,d&D A.TYPE OF ❑ I DO BLE WALLED F-]3 SINGLE WALLED WITH EXTERIOH UNER ❑ 95 UNKNOWN SYSTEM 2 SiNGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGLASS REIWORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 100%METHANOLCOMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER LINED F-]2 ALKYD LINING F-] 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED NKNOWN ❑ IS LINING MATERIAL COMPATIBLEWITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TARO ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION EileNONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 95 UNKNOWN A U 99 OTHER A U 1 STEELPRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U S 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 Co 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. y P S I VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P&6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER BVI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE -j USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLEO WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E]GALLONS 7] NO THIS FORM NAS 8FEN 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# 1 16 lcf I C°1 1, CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE ERMIT EXPIRATION DATE 1 CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY; FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED r. FACILITYISITE APPLICATION, FORM 'A',UNLESS A CUq NT FORM`A' HAS BEEN FILED DATA PROCESSING COPY