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. ... ..�..,...,..,- ... .:.,,' . STATE OF CALIFORNIff WATER RESOURCES CONTR*OARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM 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 ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED TA* FACILITY/SITE NAME WHERE TANK IS INSTALLED: aj FARM TANK-YES 01 NO Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY IO A. OWNERS TANK ID# G( �- C.YEAR INSTALLED (y D. TANK CAPACITY IN GALLONS: 000 CA) II. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. CD A. 02�1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. 1 UNLEADED E] 2 LEADED pi 3 DIESEL ' ❑3 CHEMICAL PRODUCT F-14 OIL �RODUCT ❑4 GASAHOL ❑5 JET FUEL [:16 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&C.A.S.# IV14 C.A.S.#: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER E2196 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEBUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑81 OR METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ED4UNKNGWN ❑ 99 OTHER ❑1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPOKYUNING ❑4 PHENOLIC UNING C.INTERIOR5 GLASS LINING Fj�jNLINED UNKNOWN LINING ❑ 'BUNLINED �"' ❑ IS UNING MATERIAL COMPATIBLE WITH IBB%MERIANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TAH OR ASPHALT ❑I��3,VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC L4 ( PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE U44UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITYA 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 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) " A U 4 FIBERGLASSPIPE C, MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 109%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AR 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. yy� P 8 1 VISUAL CHECK &S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS -f� P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERTMATERIAL? LlYES ❑ 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 10 C) day CURRENT LOCA %EN;Y FACT �,# APPROVED BY NAMJ,Q PHONE p WITH AREA CODE PERMIT NUMBER (Q ,•^T•,' 6(j' PERMIT APPROVAL DATE j(j/`8�P`ERRMMIITT/EXPIRATION DATE LC4 HECKp PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTp BY: FORM B(34-88) THIS FORM MUST BE ACCOMPAN'T JY A FACILITY/SITE APPLICATION, FORM �A�,UNLESS .RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY