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STATE OF CALIFOR& WATER RESOURCES CONIOL BOARD FORM 'B's UNbERGROUND STORAGE TANK PROGRAM 6D�? TANK TANK PERMIT APPLICATION INFORMATION CoMPLEtL A SEPARATEI FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIt 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED IANK t ONE ITEM ❑2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑9 TEMPORARY TANK CLOSURE ❑9 TANK REMOVED J FACtLNY/EITE NAME WNERE TANK III INSTALLED: , r ' FARM TANK-YES L I -�/,Y�G �� i-� _ fig [� n 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY H A. OWNEAS TANK ID 9 U B. MANUFACTURED BY: L,l(c_ V C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 500 II. TANK CONTENTS It(AA),18 MARKED,COMPLETE ITEM C.IF(A.1),18 NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 13 - C. ❑ I UNLEADED EADED ❑3 DIESEL 2 WASTE ❑3 CHEMICAL PRODUCT ❑/OIL ❑ 1 PRODUCT ❑ A DASAHOL ❑5 JET FUEL ❑9 AVIATION OAS ❑5 HAZARDOUS ❑SD EMPTY ❑95 UNKNOWN ❑ [-] ? METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 CA.S.1 C.A.S.R: III. TANK CONSTRUCTION MARK ONE ITEM ORLY IN Box A,S,C,A D A."M Of ❑ I W)WINALLM ❑3SIRROLEWALLED WITH E MOALNER 95twNDWN STStEM ❑2 SINGLEWALLED ❑L SECONMRr CONTAINMENT p 99 OTHER " ❑ 19TEEI.IMM ❑2 STNMESSSIEEL 0 3 FMFROlAS3 ❑1 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC IL TANK n CONCRETE ❑S POLYRNYLCLORDE ❑ ❑A IM%KUHANOLOOMPARBLEFRP MATERIAL ❑9 ma ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER G INTERIOR ❑ I RIBBERLNa ❑2 ALKYOL99NG El EPDXY LNINO EJ1 LINING LMM ❑5 Dual UK" ❑9 UNLINED 9s AMNOWN ❑ISUIMMAtER LOWATBLEW"IM%WRIANOL7 ❑YES ❑NO ❑99 MR D.CDIMDSION ❑1 POLMNLENEWRAP ❑2 TAR OR A&ITALT ❑3 WkWRAP 0 1 RBEROUM REINFORCED PLASTIC PROTECTION ❑S CATHODIC PROTECTION ❑91 NONE ©'S9 MMNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TTPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 9$i-UNKNOWN' U 99 OTHER S,CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 95 UNKNOW A U 99 0111ER A U 19TEELAPON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 9 ALUMINUM A U 9 CON R TE A U 7 STEEL CUD W/FRP A U 9 100%METHANOL COMPATIBLE ERP A U 9 GALVANZE09tEEL A U UNKNOINN� A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR 9 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. ► S 1 VISUAL CHECK P S 2 INVENTORY RECONCRIATION 01 9 3 VADOSE WELLS ► 9 1 ELECTRONIC MONITOR P 9 5 GROUND WATER MONITORING WFLLS P S S PRECISION TESTING ► S T PRESSURE TE97ING P 1 91 NONE ► S 95 UNKNOWN P 9 99 0114ER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I.ESTIMATED DATE LAST USED(MO/YRI 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MAtER1AV ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPUCAM'9 NAME(PRINTED L SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY P JURISDICTION I A�GENCY#� FACILITY ID 1 TANK IO 1 r Ed CURRENT LOCAL AOINCY PACILLTY ID 1 APPROVED BY NAME PHONE a WITH AREA CODE PERMIT NUMSIR PERMIT APPROVAL DATE PERMIT EXPIRATION DAT! CI!CK E PERMIT AMOUNT SURCHARGE AMT. FE!COD! RECEIPT A SY: al ...,,...,..,e... rile FMM ARMY N AM119MAMIFR eE A OAPR ittlelte ADM IM11GM rnnU 'A' TIMI FEE A OIIDRFMt FORMA' HAIL SFFN FII FO