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'�; F STATE OF CALIFORNAh WATER RESOURCES CONTR OARD �F FORM `B': UNDE GROUND STORAGE TANK PRRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. C'�IIFO NSP MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMITCHANGE OF INFORMATION ❑ `7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT F-]4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED ' FACILITY/SITE NAME WHERE TANK IS INSTALLED: Fou&iv it REftL? ' S - FARM TANK - YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS -IF UNKNOWN -SO SPECIFY A. OWNERS TANK ID # �(T ?, B. MANUFACTURED BY: Ww K C. YEAR INSTALLED l lo D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF (A.11. IS MARKED. COMPLETE ITEM C. IF (A.11. IS NOT MARKED. COMPLETE ITEM D- A. Xi MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ,k'2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL -P�411 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 & C.A.S. # C.A.S. #: x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM $�2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER A F-]1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS F-]4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP A ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 595 UNKNOWN ❑ 99 OTHER U 5 ALUMINUM A U ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING F-13 EPDXY LINING E]4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ;K95 UNKNOWN U 99 OTHER ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 9119'5 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A (D 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH AM 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AUU 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 06 P S 1 VISUAL CHECK (P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P© 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANKF,ILLED WITH FACILITY ID # I I$ 2( SUBSTANCE REMAINING IN INERT MATERIAL? ElYES [:]NO GALLONS PHONE # WITH AREA CODE 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 7 LOCAL AGENCY USE ONLY COUNTY # HE] JURISDICTION # I I I I AGENCY # EI I I FACILITY ID # I I$ 2( TANK ID # o 10 16:E CURRENTLOCALAGENCY FACILITY ID # AV �� APPRO B"RI PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE RA ON DATE CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT # BY: FORM B (3-7-88) THIS FORM MUST BE ACCOMPMW BY A FACILITY/SITE APPLICATION, FORM 'A', UNLE89 MRRENT FORM `A' HAS BEEN FILED DATA PROCESSING COPY �J