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STATE OF CALIFORN WATER RESOURCES CONTW RD "+ ^ FORM 'B': UNDFtGROUND STORAGE TANK PROGRAM TANKTANK PERMIT APPLICATION INFORMATION NK. z COMPLETE A SEPARATE FORM WITH THE FOLLOWING NFORMATION FOR EACH TA 1 C1 MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY C K ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOV p CAT FACILITY/SITE NAME WHERE TANK IS INSTALLED: ;.56 00 6 �F �{� �-FARM TANK-YES O ❑ w I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 9s'f/0 CTI A. OWNERS TANK 10# B. MANUFACTURED BY: W a C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS' 11. TANK CONTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. r, B G [::] l UNLEADED ❑2 LEADED ❑3 DIESEL A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑ 3 CHEMICAL PRODUCT ❑4 OIL - / ❑ 1 PRODUCT ❑ 4 GASAHOL ❑5 JET NEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY 5 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) U IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C A.S.A' HAZARDOUS SUBSTANCE STORED 8 C.A.S.R 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,&D ` A.TYPE OF ❑ 1 DOUBLE WALED ❑3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER _ ❑ 1 STEELARON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL 0A W/FIBERGLASS REINFORCE)PLASTIC B.TANK ❑5 WNC-TE ❑6 POLYWNYL CHLORIDE ❑ UMINUM ❑8 100%METHANOL COMPATIBLE TRP MATERIAL ❑9 � ❑ 10 GALVANIZED STEEL 111}L-,J�95 UNKNOWN ❑99 OTHER r,. ❑ NUM RUBBER UNED ❑2 ALLINING ❑3 EPDXY LINING NOUCUNING C.INTERIOR 5 GIASSUNt% 6 UNLINED UNKNOWN LINING ❑ ❑ 95 ❑ IS LINING MATERIAL COMPATIBLE WITH IW%METHANOL' ❑YES NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLE14E WRAP ❑2 TARORASPHALT ❑3 WRAP ❑ 4 HSS BERGUREINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 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 I 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 U 95 UNKNOWN A U 99 OTHER _ A U 1 STEEUIRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U ]STEEL CLAD W/FRP A U 810094 METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL 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. P S I VISUAL CHECK P S 2 INVENTOR/RECONCILIATION P S 3 VADOSE WELLS PELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P Arm' P S W OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED(MOLAR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL'S E]YES [::] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY pc"C-O-UNTY* JURISDICTION K AGENCY B FACILITY ID M TANK IO B _ SEM�1'FACILT'101 APPROVED BY NAME PHONEY WITH AREA CODE(�,`( PERMIT APPROVAL DATE PERMIT EXPIRATON DATE �3�PERMIT AMOUNT SURCHARGE AMT- FEE CODE RECEIPT Y B1'. ,( //�� FnR.R lFJ9-ARI THIS FORM MUST BE ACCOMPANIED BY A FACIUTY/SFTE APPLICATION, FORM 'A',UNLESS A CURRENT FORM W HAS BEEN FILED