SITE INFORMATION AND CORRESPONDENCE

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77>, STATE OF CALIFOP41A WATER RESOURCES CON`401- BOARD y•;. :: �. FORM `B': _ UX6ERGROUND STORAGE TANKOGRAM TANK TANK PERMIT APPLICATION INFORMATION ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z f MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMITCHANGE OF INFORMATION F-17 PERMANENTLY CLOSED TANK ) ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED I l' FACILITY/SITE NAME WHERE TANK IS INSTALLED: Cl FARM TANK-YES❑ NO 0' to i I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY -4 CD C!'1 A. OWNERS TANK ID q 8. MANUFACTURED BY: %j�L C. YEAR INSTALLED D, TANK CAPACITY IN GALLONS: 1400 1p 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. �MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. JNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ BO 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.P C.A.S.M III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,8,C.&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3SINGLE WALLED WITH EXTER)ORLINER ❑95 UNKNOWN SYSTEM INGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER [g-l<EL/IRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 10096METHANOLCOMPATIBLEFRP MATERIAL ❑ 9 BRONZE ❑ )0 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ C.INTERIOR 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑,6NED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION1 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A,SYSTEM TYPE A U I SUCTION A U PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U 91 NONE A U 95 UNKNOWN A V 99 OTHER A U STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE{PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 1009E 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. PB 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS � P � - PREGISIONTESTING S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK.PERMANENTLY CLOSED IN PLACE i 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH ! SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ElYES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY A JURISDICTION# AGENCY M FACILITY ID 11 TANK ID# CURRENT LOCAL AGENCY FACILITY IDA APPROVED BY NAME PHONE A WITH AREA CODJE PERMIT NUMBER PER APPROVAL DATE PERMIT EXPIRATION DATE i CHECK A PERMIT AMOUNT # SURCHARGE AMT. FEE CODE RECEIPT A BY: l FORM B(6-29-88) THIS FORM MUST BE ACCOMPANI A FACILITYISITE APPLICATION, FORM `A',UNLESS A d RENT FORMA' HAS BEEN FILED LOCAL AGENCY COPY