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STATE OF'CALIF�ORNLL WATER RESOURCES CONTR OARD FORM `B': UNDGROUND STORAGE TANK PRRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT r - CHANGE OF INFORMATION 7 PERMANENTLY ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVE FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK - YES❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS- IF UNKNOWN -SO SPIfcIFY A. OWNERS TANK ID #D_ _ B. MANUFACTURED BY: 0 C. YEAR INSTALLED jqqL D. TANK CAPACITY IN GALLONS: gno II. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. P Zt •E o`rN~ �0 c4lIFOR��P CLOSED TANK D �¢ NO JK �a A. ® 1 MOTOR VEHICLE FUEL F-] 2 PETROLEUM B. C. [:] 1 UNLEADED D 2 LEADED IK3 DIESEL VV- I ❑ 3 CHEMICAL PRODUCT 4 OIL 1 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. #: xill. 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 B. CONSTRUCTION ® 1 STEEL/IRON ❑ 2 STAINLESS STEEL F-] 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 U 4 FIBERGLASS PIPE El1 RUBBER LINED F-]2 ALKYD LINING F-]3 EPDXY LINING F-]4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING IR 6 UNLINED A U 8 100% METHANOL COMPATIBLE FRP ❑ 95 UNKNOWN A U 9 GALVANIZED STEEL A IS LINING MATERIAL COMPATIBLEEWITH 100% METHANOL? ❑ YES ❑ NO 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 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 tai® 1 SUCTION A U 2 PRESSURE /Q%% 3 GRAVITY A U 99 OTHER B. CONSTRUCTION rA) U 1 SINGLE WALLED A © 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER SURCHARGE AMT. V 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 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 BE CIRCLED. P S 1 VISUAL CHECK P S 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 TANK ID # 1J,6 SUBSTANCE REMAINING IN INERT MATERIAL? ❑ YES [:]NO APPROVED BY AME GALLONS PERMIT NUMBER THIS FORM HAS BEEN /COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APVC T'S NAME (PRIN ED & SIGNATURE) DATE 7 A cv I ICF mul v COUNTY # [�E JURISDICTION # I I I I AGENCY # FACILITY ID # EI 1 1 GC I /I �l TANK ID # 1J,6 CURRENT LOCAL A ENCY FACILITY ID # APPROVED BY AME PHONE # WITH AREA CODE PERMIT NUMBER TE PERMIT APPR71/A� P MIT EXPIRATION DATE CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODEI RECEIPT # BY: FORM B (3-7-88) THIS FORM MUST BE ACCOMPANIED -BY A FACILITY/SITE APPLICATION, 1-UHM -A-, UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY