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STATE OF CALIFORNr WATER RESOURCES CONT IOARD is• �� STORAGE TANK PROGRAM FORM B . UNDERGROUNDo TANK TANK PERMIT APPLICATION INFORMATION - COMPLETE A SEPARATE FORM WITH THE FOLLOWING'1 FORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ff� CHANGE OF INFORMATION U 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REM FACILITY/SITE NAME WHERE TANK IS INSTALLECr j' �?� t L/ c. �E FARM TANK-YES NO ;*: I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFV A. OWNERS TANK ID B. MANUFACTURED BY F C.YEAR INSTALLED D. TANK CAPACITY IN GALLON %<< v II. TANK C NTENTS IF(A.1),WMARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL 171 PETROLEUM B. /O C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL , ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT j ❑ 4 GASAHOL ❑ 5 JET FUEL VIATION GAS 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF/--'';:;,\ !g� I HAZARDOUS SUBSTANCE STORED&C.A.S.# (� � V �� C.A.S.#: XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A,TYPE OF ❑ I DOUBLE WEE ❑3 SINGLE WALLED WITH EXTERIOR LINER []],85"UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER /�❑ 1 STEEUIRON ❑2 STAINLESS STEEL F—] F—]3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK /S ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE kd-�95 7AL M ❑ 8 100%METHANOL COMPATIBLE FRP MATERIA El BRONZE El 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER /(O F-11 RUBBER LINED ❑ 2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIO LINING ❑ 5 GLASS LINING ❑6 UNLINED7� 5 UNKNOWN �I/ ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANO YES 0 ❑ 99 OTHER D.CORROSI N`r i POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VI WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION E]91 NONE UNKNOWN ❑ 99 OTHER IV. PIPING INFO NATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE ��e A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER v vn �� B.CONSTRUCTIqjp A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 5 UNKNOWN A U 99 OTHER f A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL &'` A U 5 ALUMINUM A U CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U - 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. Z P S t VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING PP S 91 NONE- 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 'ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? n 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY [CP"ENT COUNTY# JURISDICTION# AGENCY# 7� FACILITY ID# Z TANK ID# 51 <J I I I I I Ll I U1 — I I J U Ci LOCAL AGENCY FACILITY ID# A ROVED BY NAME/ �. PHONE It WITH AREA CODE LeRMIT NUMBER PERMIT APPROVAL DATE PE MIT EXPIRATION ATE CHECK# PERMIT AMOUNT SURC GE AMT. FEE CODE RECEIPT k BY: i � I K FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM—.),UNLta.;A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING CCpY