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STATE OF CALIFORNI ', WATER RESOURCESCONTRI,,,AOARD FORM B': UNDEMGROUND STORAGE TANK PROGRAM =sem TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. , MARK ONLY ❑ I 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 ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED:70�5 (,,,/� FARM TANK-YES❑ NO z 10 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C.YEAR INSTALLED III jq D. TANK CAPACITY IN GALLONS: 4600 w II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN ®'2 WASTE ❑7 METHANOL E;?IrOTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAMEOF HAZARDOUS SUBSTANCE STORED&C.A.S.# tv,%6. C.A.S.#: O XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM Z2 SINGE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER LESS STEEL 3 FIBERGLASS EEL CLAD W/FIBERGLASS CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 00%METHANOL COMPATIBLEREINFORCED PLASTIC B.TANK � ❑ ❑ ❑ MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR LINING 5 GLASS LINING F�'6 UNLINED ❑ 95 UNKNOWN ❑ ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHENEWRAP ❑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 ABO EGROUND, U IF UNDE OUND,BOTH IF APPLICABLE A SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U GRAVITY A U W OTHER B.CONSTRUCTIONU 1 SINGLE WALLED A U 2 DOUBLE WALLED A 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER AVL 1 STEEL IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U S ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 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 8 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 5 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CL SED IN PLACE 1. ESTIMATED DATEST USED(MO/YR) 2.ESTIM T QUANTITY OF 3, S TANK FILLED WITH S A EMAINING IN E MATERIAL? �YES ❑ NO GALLONS THIS FORM hAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KN LEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRIMED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# Db 2 d lo b loll CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE Ldbt PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATI N DATE CHECK# PERMIT AMOUNT - SURCHARGE AMT. FEE CODE RECEIPT p BY: J.( / RM B 13-zee) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',U111.1 A CURRENT FORMA' HAS BEEN FILED '1� DATA PROCESSING COPY