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M STATE OF CALIFORNIft WATER RESOURCES CONTIgOARD FORM `B': UNDIMROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY n1', 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 ❑ 8 TANK REMOVED /S FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1 ' S"'� FARM TANK - YES ❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID # 4J 2-5 B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Z a�jp 11. 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 ❑ 3 DIESEL F--]3 CHEMICAL PRODUCT ❑ 4 OIL Jd 1 PRODUCT ❑ 4 GASAHO❑ 5 JET FUEL ❑ 6 AVIATION GAS El 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. #: x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, &D A. TYPE OF ti< DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER B. CONSTRUCTION F-11 STEEL/IRON ❑ 2 STAINLESS STEEL .1 3 FIBERGLASS F-]4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL F-]5 CONCRETE F-16 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP U 1 STEEL/IRON ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER AO 4 FIBERGLASS PIPE F-]1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING � .Ij ° UNLINED A U 8 100% METHANOL COMPATIBLE FRP ❑ 95 UNKNOWN A U ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 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 U2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A UO 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER PERMIT AMOUNT A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) AO 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLADW/FRP A U 8 100% 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 RE CIRCLED_ P S 1 VISUAL CHECK P O 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS^ S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 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 IID # if I .i t-°' I SUBSTANCE REMAINING IN NERT 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 (PRINT D & SIGNATURE DATE p LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # AGENCY # FACILITY IID # if I .i t-°' I TTANK IID # [Ho: 1jil0 CURREN LOCAL AGENCY FACILITY ID # APP VED BY NAM PHONE #WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL E PE MIT EXPI ATION DATE CHECK # PERMIT AMOUNT URCHARGE AMT. FEE CODE RECEIPT # BY: FORM B (3-7-88) THIS FORM MUST BE ACCOMPANIED WR FACILITY/SITE APPLICATION, FORM `A', UNLESS A CLIMNT FORM `A' HAS BEEN FILED DATA PROCESSING COPY w C" c' 0