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STATE OF CALIFORN WATER RESOURCES CONTR OARD FORM `B': UNDERGROUND STORAGE TANK RAM TANK TANK PERMIT APPLICATION INFORMATION ° COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. a,P MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT // ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: vLs FARM TANK-YES❑ NO I. TANKDESCRIPTION COMPLETE ALL ITEMS t� IF UNKNOWN SO SPECIFY A. OWNERS TANK ID# 174 B. MANUFACTURED BY: C. YEAR INSTALLED t�(i. D. TANK CAPACITY IN GALLONS: ;I 'I 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. j A. Fa4rMOTOR VEHICLE FUEL [_1 2 ETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL 3 CHEMICAL PRODUCT IJ 4 OOIL ❑ 1 PRODUCT E] 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS Ili ❑5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN WASTE ❑7 METHANOL �9 OTHER(DESCRIBE IN ITEM D,BELOW) j D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF /) HAZARDOUS SUBSTANCE STORED&C.A.S.# & S f(? 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 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL [:]95 UNKNOWN 99 OTHER C.INTERIOR 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED 2"95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP F-1 2 TAR OR ASPHALT ❑ 3 VINYL WRAP El 4 FIBERGLASS REINFORCED PLASTIC PROTECTION D 5 CATHODIC PROTECTION ❑91 NONE 0 5 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 0 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH At095 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 0 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 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 PRESSURETESTING JOS 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 A//4 GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO !/ '7 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# AGENCY# FACILITY ID# TANK ID# ® 1010FI- 101AIT] olu CURRENT LOCAL AGyx ENCY FACILITY ID (�APPROVED BYE PHONE#WITH AREA CODE 7- PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANI Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS y50RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY