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STATE OF CALIFORVWATER RESOURCES CONTF BOARD FORM B': UNDERGROUND STORAGE TANK PROGRAM ' TANK TANK PERMIT APPLICATION INFORMATION 44 COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY [R<NEW PERMIT3 RENEWAL PERMIT ❑ 7 PERMANENTLY CLOS )C ❑ ❑5 CHANGE OF INFORMATION '_4 ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ ❑6 TANK REMOVED I �,l FACILITY/SITE NAME WHERE TANK IS INSTALLED: - QQ -11"r FARM TANK-YES❑ NOS❑ 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IDN B. MANUFACTURED BY: C. YEAR INSTALLED Q- O. TANK CAPACITY IN GALLONS QV Y II. TANK CAhTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,CO___3APLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM 8. C. UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑BO 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.K C.A.S.W Ill. TANK CONSTRUC ON MARK ONE ITEM ONLY IN BOX A,B,C,AD A TYPE OF I DOUBLEWAl1ID ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑:2! ❑ 1 STEEUIRON ❑2 S'TAINLESSSTEEL ❑ 3 RBERGLASS 4 STEEL CLAP W/FIBERGLASS REINFORC9D PLASTIC B'TTANK ATERIAL ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑6 700%METHANOLCOMPATIBLEFRP ❑ 9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ C. INTERIOR 1 RUBSERUNED ❑2 ALKYD UNING ❑3 EPDXY UNING ❑4 PHENOUCUNING LINING ❑5 GLASS UNING ❑ 6 UNUNED UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? C-]YES E] No 1a1 'OTHER U K��`-k� D. CORROSION ❑ I POLYETHLENE WRAP ❑2TAR OR ASPHALT ❑ VINYL WRAP 4 FIBERGLASS REINFORCED PLISHC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE �UNKNOWN 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 GRAVITY A U 91 NONE A U 5 UNKNOWN A 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 5 UNKNOWN A U 99 OTHER A U 1 STEEUIRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM ALA CONCRETE A U 7 STEEL CD W/FRP A U S 10096 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A/--- 5 UNKNOWN A U 99 OTHER 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 S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELL S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS H PS 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S N OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED I R) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? [:]YES �O 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 N JURISDICTION M AGENCY N FACILITY IDN �' I TANK ID N m 3 CURRENT LOCAL AGENCY FACILITY IDk APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PMI XPIRATION y: �I1 \' CNECKN PERMIT AMOUNT SURCHARGE ANT. FEE CODE ^�CEIPTN BY: FORMBE-29-881 THIS FORM MUST BE ACCOMPANIED-dY A FACIUTY/SITE APPLICATION, FORM 'A',UNLESS A&4RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY