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STATE OF CALIFORNI7 WATER RESOURCES CONTRO OARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION Qp COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z MARK ONLY ❑ ❑ ❑ ❑ I O 1NEWPERMIT 3RENEwAL PERMIT SCHANGEOFINFORMATION ]PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: d If 50 IF. F FARM TANK-YES I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 41111 A. OWNERS TANK ID# G S. MANUFACTURED BY: tl-�o 1V C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: D II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. aall�, MOTOR VEHICLE Ll 1 UNLEADED ED 3 DIESEL A ❑3 CHEMICAL PRODUCT F-1 4 OIL PETROLEUM B 1 PRODUCT C ❑4 GASAHOL ❑ 5 JET DUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ❑99 OTHER(DE5CRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.# Al C.A.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A.TYPE OF ❑ 13PBLEWALUED F—] 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM LEWAU.ED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER STEELPRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 100%METHANOLCOMPATIBLEFRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBERLINED ❑ 2 AU(YD LINING 3 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑ 5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ❑ (SEINING MATERIAL CGMPATIBLEWITH IW%METHANOL? 2YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2TAR OR ASPHALT ❑ 3 RK 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 U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 5 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U / SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I 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 STEELCLADW/FRP A U 8 /00%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A ip 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 �S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S)6 PRECIS IONTESTING P S 7 PRESSURETESTING P S 91 NONE P S 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 3.WAS TANK FILLED WITH 17 GALLONS N SUBSTANCE REMAINING IN INERT MATERIAL? [:]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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION# AGENCY# FACILITY ID# TANK ID# Ino I I 111 D 1 17 16101 CURRENT LOCAL AGENCY FACILITY ID# APPRO DY N ME PHONE#WITH AREA C DE PERMIT NUMBER PERMIT APPROVALGISAtE PERMIT EXPIRATION DATE CHECK p PERMR AMOUNT SURCHARGE AMT. FEE CODE RECEIPT* BY: FORM a(6-29-66) THIS FORM MUST BE ACCOMPAILED BY A FACILfTY/SITE APPLICATION, FORM 'A',UNLESS.-CURRENT FORMA' HAS BEEN. DATA PROCESSING COPY