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STATE OF CALIFORNV' WATER RESOURCES CONTRC `OARD FORM B': UNDERGROUND STORAGE TANK PROGRAM 3m� TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY F-11 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK IG ❑ ❑ ONE ITEM F-12 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: S Y I WAA.1 FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—S SPECIFY CD CD A. OWNERS TANK ID# B. MANUFACTURED BY: 09 C. YEAR INSTALLED 11172, D. TANK CAPACITY IN GALLONS: ,Z D II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.11),IS NOT MARKED,COMPLETE ITEM D. A. Eyl MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL I PRODUCT ❑-4 GASAHOL ❑5 JET FUEL 6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY 0 9 UNKNOWN IL=JI 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.# C.A.S.W III. TANK CONST CTION MARK ONE ITEM ONLY IN BOX A,B,C.8 D A. TYPE OF 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARYCONTAINMENT ❑ 99 OTHER 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEELCUD W/RBERGLASS REINFORCED PLASTIC B. TANK ❑ MATERIAL 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 UMINUM ❑B 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER C. INTERIOR F-1i RUBBER LINED ❑2 ALKYD LINING F-13 EPDXY LINING ❑4 PHENOUC LINING LINING ❑5 GLASS LINING ❑6 UNLINED ❑ NKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO x990 D. CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT Ej 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLEWALLED A U 2 DOUBLEWALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 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 STEELCLAD 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. 104 k 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS 6 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF TWA TANK FILLED WITH SUBSTANCE REMAINING INGALLONS INERT MATERIAL? ❑VES ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGE CY FACILITY ID p APPROVED BYNAME +' PHONE N WITH AREA CODE B el' 23 , UMBER PERMIT APPROVAL DATE PERMIT tXPIRATION OATE PERMIT AMOUNT SURCHARGE ANT. FEE CODE RECEIPT N BY: THIS FORM MUST BE ACCOMPANIED bT A FACILITY/SITE APPLICATION, FORM'A',UNLESSACU ENT FORMA HASSEENFILED DATA PROCESSING COPY