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STATE OF CALIFORNS, WATER RESOURCES CONTR OARD FORM `B': UNDE GROUND STORAGE TANK PRORAM O TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM f�2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED:eu c�FARM TANK - YES ❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN — SO SPECIFY A. OWNERS TANK ID # '�,I ),,/, �_�� r B. MANUFACTURED BY: I C. YEAR INSTALLED I I ► )I_ I D. TANK CAPACITY IN GALLONS: I (V-l%i \-I II. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.11. IS NOT MARKED. COMPLETE ITEM D. A 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED fj�'3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL x"l 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. #: xill. 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 W2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER A F-11 STEEL/IRON ❑ 2 STAINLESS STEEL F-]3 FIBERGLASS F-14 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE F-]7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP A U ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ;�J'95 UNKNOWN ❑ 99 OTHER U 5 ALUMINUM A U ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING F-13 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN 95 UNKNOWN 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 -1>—?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( 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A Cl 95 UNKNOWN A U 99 OTHER CHECK # --]-'PERMIT 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 A e 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 1 VISUAL CHECK POS 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS PO 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 TANK FILLED WITH FACILITY ID # i I 1:7,-1 ) I SUBSTANCE REMAINING IN INERT MATERIAL? [:]YES ❑ 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 LOCAL AGENCY USE ONLY COUNTY # � JURISDICTION # I I 1 —1 AGENCY # EI I IDDI FACILITY ID # i I 1:7,-1 ) I TANK ID # Fol f) I o f-9 CURRENT LOCAL AGENCY FFAACILITY ID # hfmz APPROV PHONE #WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE IT EXPIRA ON DATE j CHECK # --]-'PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT # BY: I FORM B (3-7-88) THIS FORM MUST BE ACCOMPAIM BY A FACILITY/SITE APPLICATION, FORM `A', UNLE9.10,'URRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY V., J