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STATE OF CALIFORNI# WATER RESOURCES CONTRI&OARD '• UNDERGROUND STORAGE TANK PRRAM FORM B . U W o TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWI NFORMATION FOR EACH TANK. `"If wt MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 RANGE OF INFORMATION ❑ 7 PWMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED DG( FACILITY/SITE NAME WHERE TANK IS INSTALLED: � - hzz �� FARM TANK - YES ❑ NO 1 I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID # UKB. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 4900 II. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. A 1 MOTOR VEHICLE FUEL F-] 2 PETROLEUM B. C F-]1 UNLEADED ❑ 2 LEADED 3 DIESEL F-13 CHEMICAL PRODUCT ❑ 4 OIL IJ ' 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. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D A. TYPE OF ❑ DOUBLE WALLED F--]3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM U ` SNGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER A U 95 UNKNOWN A U 99 OTHER 1 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 A F-]1 RUBBER LINED F-12 ALKYD LINING El3 EPDXY LINING PHENOLIC LINING C. INTERIOR LINING F-]5 GLASS LINING ❑6 UNLINED 6 CONCRETE V95UNKNOWN U ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALTe95 NYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE NKNOWN ❑ 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 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE AU�5 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 A U 91 NONE 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& 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 CP S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WA 12 MONITORING WELLS P k6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P�99 OTHER L 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 # SUBSTANCE REMAINING IN INERT MATERIAL? 1:1YES ❑ NO IZ GALLONS o I o 1 I �(�` I. 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 f1riT•TNIllF--Ta lT@WAIki3.7I1\/ FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIED BTICFACILITY/SITE APPLICATION, FVKM 'A', UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY z 10 H. • JURISDICTION # AGENCY# FACILITY ID # TANKID# ECOl,�UfNAMETYE1# IZ I o I o 1 I �(�` I. d )-3 AGEENNCY FACILITY ID # APPROVED BY NAME PHONE # WITH AREA CODE r PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE RE EIPT # BY: FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIED BTICFACILITY/SITE APPLICATION, FVKM 'A', UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY z 10 H. •