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i . . . -�- i STATE OF CALIFORNWb NK WATER RESOURCES CONTR OARD FORM 'B': UNDE GROUND STORAGE TAPRORRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. C7 MARK ONLY ❑ I NEIN PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE l J B TANK RFMOVFD C.A.I FACILITY/SITE NAME WHERE TANK IS INSTALLED:A Qyy�l , C( � FARM TANK.YES NO ❑ C)"1 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID N B. MANUFACTURED BY: C YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A EV MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEAOEO ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL 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 8 C.A.S.N C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,6 D A.TYPE OF ❑ I DOUBLE WAILED ❑3 SINGLE WALLED WITH I XII NOR LINER F,+,-,-,,KNOWN SYSTEM ❑2 SINGLE WAAED ❑4 SECONDARY CONTAINMENT ❑99 OTHER _ ❑I STEEL/IRON ❑2 STAINLESSSTEEL �❑3 FSERGLASS ❑4 STEEL CLADw7F18ERGLASSREINFORCED PLASTC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 1DD%METHANOL COMPATIBLE FPP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL UNKNOWN ❑99 OTHER ❑ C.INTERIOR I RUBBER LINED ❑2 ALKYD LINING (❑ 3 EPDXY LINING ❑4 PHENOLIC LINING LINING F-]5 GLASS LINING El UNLINED 5 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL7 ❑YES ❑NO riKOTHER_ D.CORROSION �❑ I POLYETHLENE WRAP ❑2 TARORASPIIALT ❑1 3 VI LWRAP ❑4 FIBERGIASS REINFORCED PIASTIC PROTECTION _]5 CATHODIC PROTECTION ❑9I NONE 5 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 2 PRESSURE A U 3 GRAVITY A U 91 NONE A"U5 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED 1HENCH A U 91 NONE A 5 UNKNOWN A U 99 OTHER A U I STEFL/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 ALUMINUMA 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U 5 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. 3 t VISUAL CHECK P S 2 INVENTORY RECONCILIATION P ELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 9 6 PRECISION lES1WG P S 7 PRESSURE TESTING P 8 91 NONE P 3 95 UNKNOWN P S 99 01 HER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED LVO/YRI 2. ESTIMATED OUANTIIYOF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN —GALLONS INERT MATERIAL? [_]YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED b SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION N AGENCY N FACILITY ID M U TANK ID H *- ", __ _ CURRENT LOCAInAPENCY FACILITY IDN / APPROV D BYN Ea PHONE Y WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DAT PERMIT EXPIRATION DATE _ - _- CHECK IN PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORM D(6 29 88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY