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STATE OF CALIFORNI WATER RESOURCES CONTR( )OARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM _' TANK TANK PERMIT APPLICATION INFORMATION o b COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 EW PERMIT F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CL NK ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED:77 Z t f Ot FARM TANK-YES❑ NO Rr z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY L� A. OWNERS TANK IDR -z- B. MANUFACTURED BV: C.YEAR INSTALLED n ; D. TANK CAPACITY IN GALLONS: DO A 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. N A. Dp�1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL olf PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 60 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. All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.A D F-1 3 siNrLEWALLED WITH 95 UNKNOWN A. SYSTEM �SI�NG EE ALLEDD ❑4 SECONDARf CONTAINMENT LINER ❑W OTHER I STEELARON ❑2 STAINLESS STEEL ❑ 3 RBERGM ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE 6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE RIP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER ❑ 1 RUBBERUNF'D ❑2 LINING ❑3 EPDXYUNING ❑4 PHENOLIC LINING C.INTERIOR LINING ❑5 GLASS LINING UNUNm ❑95 UNKNOWN ❑B UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP 2 TM OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMAT ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLI CABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION Alm 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A b 95 UNKNOWN A U 99 OTHER Vfi. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. I P S 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S d ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS I� P 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMAT D DATE LAST USED(MO/YR) 2. ESTIMATED UANTITY OF 3.WAS TANK JILLED WITH SUBS A MAINING IN GALLONS INE IAL? [—]YES ❑ NO THIS ORM HAS BEEN COMPLETED UNDER PENALTY d PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY R FACILITY IDR TANK ID R 13 1 ! 11 100 16 - CUR NT LOCAL AGENCY FACILITY ID R APP 1�AME�y_ / PHONE Y WITH AREA CODE PERMRNUMBER PER TAP OVAL DA dOQPPERi/MIIITEXPIRATION DATE • C CHECK N PERMIT AMOUNT SURD R E AM FEE CODE RECEIPT X BY: FORM B(3-7-86) THIS FORM MUST BE ACCOMPANIEDBT A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORM'R HAS BEEN FILED DATA PROCESSING COPY