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TATE OF CALIFORN WATER RESOURCES CONTP jOARD ,.°:.r>. �s FORM `B': UNDERGROUND STORAGE TANK PROGRAM rTANKTANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT [a'5-CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOV D�� FACILITY/SITE NAME WHERE TANK IS INSTALLED• y. n. �:, FARM TANK-YES❑ NO 1. TANK DESCRIPTI COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID - — _ U/Z B. MANUFACTURED BY C. YEAR INSTALLEDL-41L D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. E``5 A. ❑ 1 MOTOR VEHICLE FUEL 2 PETROLEUM C. ❑ 1 UNLEADED Ea-LEADED ❑ 3 DIESELco R ❑ 3 CHEMICAL PRODUCT F74 OIL d. 1 PRODUCT ) ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS l ❑ 5 HAZARDOUS El 80 EMPTY E]95 UNKNOWN ❑ 2 WASTE C / ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME 7",ti`s HAZARDOUS SUBSTANCE STORED&C.A.S.#1 FaC� /+� C.A.S.#:( L'{//� I x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF �. ❑ 1 DOUBLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM ) ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER fF t❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL GLAD W/RBERGLASSREINFORCED PLASTIC B.T AnK C7 ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALU INUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 5 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING F--] 4 PHEN IC LINING C. NT NRGIO � ❑ 5 GLASS LINING ❑6 UNLINED ; 5 UNKNOWN r`1 ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL ❑YES 0 ❑ 99 OTHER D. CORROSI041� ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 39 WRAP F-14 FIBERGLASS REINFORCED PLASTIC PROTECTI ❑ 5 CATHODIC PROTECTION ❑91 NONE i ' 5 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE (Ii A U 1 SUCTION A >2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTIO <V A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A en95 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 C. MATERIAL 't( 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 5 UNKNOWN A U 99 OTHER t V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. � S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS y1e P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE .;ESTIMATED DATE LASTED ED(M /YR) ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH 2 �.2, SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? 7 YES n 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 iCOUNTY# JURISDICTION# AGENCY# FACILITY ID# /TANK ID# I --M Eo I c) I o 17 I I I i El I I [22—cl I CIURRENT LOCAL AGENCY FACILITY ID# A ROVED BY NAME PHONE#WITH AREA CODE —16 � y MIT NUMBER p IT,APPROV ATE ERMIT EXPIRATIOA DATE / No CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM;'UNLh..:A CURRENT FORM'A' HAS BEEN FILED ❑ATA PROCESSING COPY