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STATE OF CALIFORNI ' WATER RESOURCES CONTRf- 90ARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION ao COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - _ _ z MARK ONLY 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK 80 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED t/)/ FACILITY/SITE NAME WHERE TANK IS INSTALLED: OZ w FARM TANK-YES❑ NO (,V 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SOS FY 01 A. OWNERS TANK ID k 0 B. MANUFACTURED BY: GC C. YEAR INSTALLED ezD. TANK CAPACITY IN GALLONS: ._ 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 2�11`MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL pt j-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.p: III. TANK CONSTRUCTION MARK ONE ITEM ONL IN BOX A,B,C.&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM �j 2 SINGLE WAUM ❑4 SECONDARY CONTAINMENT ❑99 OTHER �rlTEBJIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CIAO W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FAP ❑9 BRONZEI❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F7 RUBBEKUNED LKYD LINING F-13 EPDXY LINING ❑4 PHENOUC LINING LINING F-] 5 GLASS LINING 6 UNLINED n 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ,L f99 OTHER D. PROTECTION ❑5 CATHODIC PROTECTION ❑91NE WRAP E]2 NONE ASPHALT n 95 KNOWN ❑99OTH USS REINFORCED PLASTIC IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IFUNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A 1 STEEL/IRON A U 2 STAINLESSSTEEL 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 B 10D%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A 95 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR 8 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 3 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S d ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS J P 6 PRECISIONTESTIN P S ] PRESSURE TE STI NG P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED ATE LAST USED(MO/YR) 2. ESTIMATED 01,1ANTITY OF 3.WAS TA K LLED WITH SUBST C E INING IN IN T A R L7 VES E] NO-]GALLONS THIS F RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLED E,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY I CCOUINTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID^# ll[2P .l V `/ IV CURRENT LOCAL AGENCY FACILITY ID# APPROV BY/NNA E PHONE N WITH AREA CODE i V PERMIT NUMBERPERMIT A OVAL DA ERMIT EXPIRATION DATE 7 ti CHIPERMIT AMOUNT SUR RGE T. FEE CODE RECEIPT N BY: FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIE:-YA FACILITY/SITE APPLICATION, FORM 'A',UNLESS RENT FORMA HAS BEEN FILED f^A"':.^ AROCFr.", N . '.::w