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STATE OF CALIFORNI/ WATER RESOURCESCONTRO' OARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM ' TANK TANK PERMIT APPLICATION JINFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN I INFORMATION FOR EACH TANK. G MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EB45 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK (0 ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED ✓C FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES F-1NO CD Q I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY CA) A. OWNERS TANK ID# B. MANUFACTURED BY: Oc*wx-S CD C. YEARINSTALLED 8( D. TANK CAPACITY IN GALLONS: 11. TANK PONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,9OMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. Erl UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CA.S.# C.A.S.M III. TANK CONSTRU TION MARK ONE ITEM ONLY IN BOK A,B,C,S D A TYPE OF IDOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 SM/IRON ❑2 STAINLESS STEEL 3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑810M METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED S1Ea ❑ 95 UNKNOWN ❑99 OTHER ❑ LINED ❑2 ALKYD UNING F-13 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR LINING 5 GLASS UNING ❑6 UNLINED ❑ 95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION 1 � PROTECTION ❑ 5 CATHODIC PROTECTION 91TAR OR NONE ASPHALT 3 VINYL WRAP❑ 95 UNKNOWN 099 OTEHER ffiREINFO PLASTIC IV. PIPING INFORMATION CIRCLE AIF ABOV GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION PRESSURE A U 3 GRAVITY A U 91 NONE A U 96 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED U DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 96 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) IBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,ORS FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P 8 3 VADOSE WE P 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE . ESTIMATED DATE LAST USED IMO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES E]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# L CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE us-32v PERMIT NUMBER PERMIT APPROVAL DATE PER EXPI TION DATE CXECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: mM - FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIEDTY A FACMFFf SITE APPLICATION, FORM `A',UNLESS A C RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY _ _