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STATE OF CALIFORNI. ' ,* �°� �41ATER l;ESOUFtd✓I�S C(�N�'RC tZARD °.p/tb��+A. FORM `B9: UNDERGROUND STORAGE TANK PROGRAM `�� ^' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK- MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PMMIT 5 CHANGL OF INFORMATION C] 7 PERMANEKI LY(LUSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E]6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED �S' FACILITY/SITE NAME WHERE TANK IS INSTALLED: Z 3 FARM TANK-YES❑ No liell I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY •O A. OWNERS TANK ID N B. MANUFACTURED BY: �/ C. YEAR INSTALLED W(/ D TANK CAPACITY IN GALLONS: QQc) II. 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 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION 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 HAZARDOUS SUBSTANCE STORED B CA.S.N CA.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A TYPE OF ❑ BLE WALE ❑ 3 SINGLE WALLED WITH EXTERIOR LW ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑NK I STEEL/F90N El STAINLESS STEEL E]3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED P ASTIC B. MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLOAIOE 1"INUM ❑8 100%METHANOLCOMPATIBLEFRP ❑ 9 BRONZE ❑ 10 GALVANUO STEEL U' "'"NOWN ❑99 OTHER 1 RUBBER LINED F-12 ALKYD LINING �3 EPDXY LINING ��K OLIO LINING C INTERIOR LINING ❑5 GLASS LINING ❑ 6 UNLINED ❑IS LINING MATERIAL COMPATZLE WrrH 100%METHANOL? V3UN= NOVOT:7- D. CORROSION ❑ I POLYETH'LENEWRAP 2 TAR OR ASPHALT ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION 91 NONE ❑ 99 OTHEfl IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 TION A U 2 PRESSURE A U 3 GRAVITY A U 9t NONE A U.25 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 S UNKNOWN A U 99 OTHER A U I STEELARON 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 A6 CONCRETE A U 7 STEEL CLAD W/FRP A U B I DO%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEE, A U 95 UNKNOWN A U 99 OTHER V. AK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE C{RCLED. 1 P 1 VISUAL CHECK P 6 2 INVCNTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING P S 7 PRESSURE TESTING P 6 91 NONE P 5 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2 ESTIMATED OUANTITY OF 3, WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E]YES Ej 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 Q SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY 0 JURISDICTION A AGENCY t FACILITY 10 4 TANK ID M CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE 4 WITH AREA CODE N PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK 6 PERMIT AMOUNT SURCHARGE AMT. FEE CODE 1 RECEIPT M BY: FORM e(6-29-88) THIS FORM MUST BE ACCOMPANIED RY A FACII m/SITE APPI WATInu GnczLA -A' 1