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STATE OF CALIFORNI.,... WATER RESOURCESCONTRc„�ZJOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM k ` TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. :J MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE El 8 TANK REMOVED 0 �- Q N FACILITY/SITE NAME WHERE TANK IS INSTALLED: (� µµ'yy. .Ly (,� I/f FARM TANK-YES❑ NO V1 J I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIF -4 A. OWNERS TANK ID qway%zB. MANUFACTURED BY' 00 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS'. OQ 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 F--] 2 PETROLEUM B. C. I UNLEADED E:] 2 LEADED ❑ 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ ED 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.R C.A.S.N'. 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B.C.A D A.TYPE OF I BLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2 3W WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEDUIRON ❑ 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 ❑ I RUBBER LINED ❑2 KYD LINING E]3 EPDXY LINING ❑4 PHENOLIC LINING O C.INTERIOR LINING ❑ 5 GLASS UNING 6 UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%MEFHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑f POLYETHLENEWRAP ❑2 TAR OR ASPHALT F-] 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION EV5 CATHODIC PROTECTION 0 91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 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 A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD WERE A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER A/V. LEAK DETECTION $ STEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 1 VISUAL CHECK 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS fY YYY�� P 6 PRECISION TESTING 8 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED IMO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ 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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY P JURISDICTION A AGENCY M FACILITY 10 A TANK ID# EH = 1- P I I o IA CURRENT LOCAL AGEN�Y FACILITY ID N APPROVED BY NAME PHONE 0 WITH AREA CODE Cr/ /lca PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK Y PERMIT AMOUNT SURCHARGE AMT. FEE CODE ^"ELFT N BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED