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STATE OF CALIFORNIn WATER RESOURCESCONTRC,,,OARD :•'?^ FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION % COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - z 10 MARK ONLY F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS NK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVE N FACILITY/SITE NAME WHERE TANK IS INSTALLED: (� ' ►9A OrjFARM TANK-YES❑ NO EVO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY SZ� A. OWNERS TANK IDR q I B. MANUFACTURED BY: C. YEAR INSTALLED ' D. TANK CAPACITY IN GALLONSV (/ II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A 3 CHEMICAL VEHICLE FUEL [:]2 PETROLEUM B 1 PRODUCT C ❑ 1 UNLEADED [:]2 LEADED ❑ 3 DIESEL ❑ 4 GASAHOL ❑5 FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS E] BO EMPTY ❑ 95 UNKNOWN ❑2 WASTE E] 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C A.SR Al /W/4/ Vd(e , C.A.B.R: /Ob y 3SZ III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.6 D A TYPE OF ❑ BLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER nEL/IRON ❑2 STAINLESS STEEL F-13 FIBERGLASS ❑ /STEEL CLADWIFlBERGlAS6 REINFORCED PLASTIC B.TANK 5 CONCRETE ❑6 POLYWNYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE RIP MATERIAL 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER UNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑T-�"1�4�PHENOLIC LINING LINING ❑ 5 GLASS UNING ❑6 UNUNED '" NKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH iW%METHANOL? ❑YESNNNyyylll❑ NO �THER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TARORASPHALT ❑WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC 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 A V 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON 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 A6 CONCRETE A U ]STEEL CLAD W/FRP A U B 10096 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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. 01) 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS oyll-luP 8 6 PRECISION TESTING P 8 PRESSURE TESTING P S 91 NONE P 8 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 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY R FACILITY ID R TANK ID# M = = 1010111719111 10101 �I $fl CURRENT LOCAL AGENCY FACILITY ID R APPROVED BY NAME PHONE#WITH AREA CODE D PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE (7 CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECMPT# FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILFTY/SITE APPLICATION, FOR M 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED