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STATE OF CALIFORNS WATER RESOURCES CONTROBOARD FORM'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED lS FACILITY/SITE NAME WHERE TANK IS INSTALLED: d. S I P ^J FARM TANK -YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN — SO SPECIFY A. OWNERS TANK ID 0 �— B. MANUFACTURED BY: CIA—A-/ C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: ®`(� II. TANK CONTENTS 4 10 n r^UDI rrr ITrM c IP IA 11 IR NOT MARKED- COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 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. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D A. TYPE OF ❑ I DOU LED F-]3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLEWAUED ❑4SECONDARY CONTAINMENT 99 OTHER U 3 GRAVITY A U NONE ❑ 1 STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑7 ALU INUM ❑ 6 10096 METHANOL COMPATIBLE FRP MATERIAL E:].. 9 BRONZE ❑ 10 GALVANRED STEEL UNKNOWN - ❑ 99 OTHER U ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PH OLIC LINING C. INTERIOR GI ❑ 5 GLASS LINING ❑ 6 UNLINED A 5 UNKNOWN 5 ALUMINUM A U 6 CONCRETE ❑ IS LINING MATERIAL COMPATIBLE WITH_>A METHANOL? ❑ YES. ❑ NO R'99 OTHER�� D. CORROSION ❑ 1 POLYETHLENEWRAP 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4, FIBERGLASS REINFORCED PLASTIC 1, PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICAB JURISDICTION # AGENCY # A SYSTEM TYPE A(U 1 SUCTION - A U 2 PRESSURE A U 3 GRAVITY A U 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 91 NONE Jrinp5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE IPVC) A U 4 FISERGLASSPIPE A U 91 NONE BY: C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U S 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A n5 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 ©S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS ' P O 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 LA T USED /YR) 2. ESTIMATED OUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E]YES [:]NO THIS FORM AS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME (PRINTED & SIGNATURE) I DATE I nPAI ArFury I IS:P nNl V COUNTY # JURISDICTION # AGENCY # FACILITY ID R TANK ID # CURRENT LOCAL AG CY FACILITY IDN APPROVED BY NAME PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATIONVATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM U (6-29-88) THIS FORM MUST BE ACCOMPANIMNY A FACILITY/SITE APPLICATION, F V HM 'A', UNLESS A=RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY z IO .w W N O)