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STATE OF CALIFORN14S WATER RESOURCES CONTROARD FORM `B': UNDERMTROUND STORAGE TANK PROAM rr TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 10 f MARK QNLY w 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT [-]6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 11751 wi. E Ylw w FACILITY/SITE NAME WHERE TANK IS INSTALLED: ( eA FARM TANK-YES NO (� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID It B. MANUFACTURED BY: U'W041zl 40" 161 i C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 0,ewe), II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. I A. 5? 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 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 El 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# ZA C.A.S.#: ��LA III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D �{ A.TYPE OF i DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE E]6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100%METHANOL COMPATIBLE FAP MATERIAL ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER C. INTERIOR F-] 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING E] 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING6 UNLINED E] 95 UNKNOWN ' ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ®'YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP Nr4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABO%E GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE AU 1 SUCTION A V2 PRESSURE A 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED AU 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER 41 U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A we8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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 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 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) nUBSTANCE;VtXG STIMATED QUANTITY OF 3. WAS TAN FILLED WITH IN INERTM T RIAL? ❑YES E] NO GALLONS N THIS FORM HAS BEEN COMPLETED UND R P LTY OF PERJURY,AND TO THE BEST OF MY KNOWLE GE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATUR DATE LOCAL AGENCY USE ONLY �! COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 2` d CURRENT LOCAL AGENCY FACILITY ID# APPR m PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE P MIT EXPIRATION DATE t r .CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: Am FORM a(s-2s-SS) THIS FORM MUST BE A COMPA BY A F LITYAM APPLICATION, FORM ` NLESS RE ORM'A' HAS BEEN FILED DATA PROCESSING COPY