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4.2 — 13TATE OF CALIFO SNI/ WA7ER RESOURCES CONTRO` '`BOARD ,� \ I 9 FORM B -. UNDEF�GROUND STORAGE TANK PROG-AAM q 0VEr) TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT U2 5 CHANGE OF INFORMATION ❑ 7 PFRMIANENTLYCLXQD TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE b FACILITY/SITE NAME WHERE TANK IS INSTALLED: f o`�y L� J ((fl FARM TANK-YES NO g I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# (,�yLk4# f o B. MANUFACTURED BY: �Zy yL W C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 6000 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 ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIE -L ❑3 CHEMICAL PRODUCT F-14 OIL RT PRODUCT E]4 GASAHOL ❑ 5 JET FUEL AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,8E(OW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8,C.A.S.# C.A.S.# 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,3 D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER pj-9;UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC B'TANKRIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE Y9'5 ALUMINUM ❑8 IN%METHANOL COMPATIBLEFRP MATE ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER ❑1 RUBBER UNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4NOLICUNING C.INTERIOR S GLASS LINING 6 UNLINED 95 UNKNOWN LINING � ❑ ❑ IS LINING MATERIAL COMPATIBLE WITH IN%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3-'VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION "❑ 5 CATHODIC PROTECTION ❑91 NONE d95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IFUNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 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 U 95 UNKNOWN A U 99 OTHER i 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 W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER i V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS I P S 5 PRECISION TESTING ^ 7 PRESSURETESTING P S 91 NONE P 5 95 UNKNOWN P S 99 011-1EH VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1,ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY M/-- ,� r:_ r 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO i THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID 0 'TANK ID# I I I I I I T---1 I I T--m CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE It WITH AREA CODE ��ItVK 3 1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT 4 BY: