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STATE OF CALIFORNI WATER RESOURCES CONTRC `OARD FORM 'B': UNDERGROUND STORAGE TANK PRO ,UhAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. -- MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EJ CHANGE OF INFORMATION ❑7 PERMANENTLY C NK 10 ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT`` '' [_]6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: t/l7 0 AA FARM TANK-YES NO ❑ N 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY W W A. OWNERS TANK IDN B. MANUFACTURED BY: ja C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: D II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A. I MOTOR VEHICLE FUEL F-] 2 PETROLEUM B. C. ❑ 1 UNLEADED ffr 2 LEADED ❑3 DIESEL ❑3 CHEMICALPRODUCT ❑ 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&CA.S.N C.A.S.W III. TANK CONSTRUCTION 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 ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE UMINUM ❑8 160%METHANOL COMPATIBLE ERP MATERIAL ID9 BRONZE ❑10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑3 EPDXY LINING gENKNOWN OLICUNING C. INTERIOR LINING ❑5 GUSS UNiNG ❑ 8 UNLINED IS LINING MATERIAL COMPATIBLE WITH 1Do%METHANOL? ❑YES ❑NO E# D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VWfl.WRAP ❑4 FIBERGLASSREINFORCEDPLASTIC 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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A UNKNOWN A U 99OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A rgfi UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM ;q=CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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 1VISUAL CHECK P 8 2 INVENTORY RECONCILIATION 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURETESTING 8 1 NONE P S 95 UNKNOWN P $ 99 OTHER VI. INFORMATION ON TANK PERMANENTL CLOSED IN PLACE 1. ESTI TED DATE LAST USED(MO/YR) 2. ESTIMA ED QUANTITY OF 3.WAS NK FILLED WITH S �1 E REMAINING IN GALLONS TERIAL? ❑YES ❑ 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# JURISDICTION# AGENCY# FACILITY IDN TANKID# Edo dl CURgiNT L CAL AGENCY FA ILITY ID N APPRO ED BY N PHONE#WITH AREA CODE NU PERMITNUMBER PERMIT APPROVAL DATE PEANUT EkPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM 0(6-29-66) THIS FORM MUST BE ACCOMPANIEOW A FACILITY/SITE APPLICATION, FORM 'A',UNLESS AttNIRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY