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STATE OF CALIFORNI f WATER RESOURCES CONTRr' 10ARD FORM 'B': UNDE*GROUND STORAGE TANK PROGRAM TANK (i TANK PERMIT APPLICATION INFORMATION ®' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEWPERMIT ❑3 RENEWALPERMIT IV5 CHANGE OF INFORMATION ❑7 PERMANENTLYCLO NK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE FACILITY/SITE NAME WHERE TANK IS INSTALLED: 6ji [, FARM TANK-YES❑ NO z 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 1 O A. OWNERS TANK ID N B. MANUFACTURED BY: ML C. YEAR INSTALLED t- D. TANK CAPACITY IN GALLONS: W 11. TANK NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. a A. gi MOTOR VEHICLE FUEL ❑2 PETROLEUM8. C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESELDo 3 CHEMICACPRODUCT ❑ 4 OIL /1PRODUCT ❑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.R C.A.S.N: III. TANK CON,WfRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2LE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER rG 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDEINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYOUNING ❑ 3 EPDXY LINING F-144 PHENOUC LINING LINING ❑ C. INTERIOR 5 GLASS LINING ❑6 UNLINED , HE/// NOWN ' ❑ IS UNING MATERIAL COMPATIBLE WITH 100%MEAWOL? ❑YES ❑NO OTHER D. CORROSION ❑ 1 POLYEiHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3 WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A&ZI SUCTION A U 2 PRESSURE A U 3 GRAVITY A Rn,99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH 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 FI*E LASSPIPE C. MATERIAL A U 5 ALUMINUM A jn6 CONCRETE A U 7 STEELCLADW/FRP A U 8106%METHANOL COMPATIBLEFRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. 4AK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. - P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS DP S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN OALLON8 INERT MATERIAL? DYES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY k JURISDICTION b AGENCY N FACILITY ID 4 TANK ID N Do o D0 1 o I / CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER /I YA1'/ PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT p By-1 1 44-1a FORMS(3-7-88) THIS FORM MUST BE ACCOMPANIED eY A FACILITY/DATA PROCESSING, C W,UNLES�uRRENT FORMA' HASBEEN FRED