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STATE OF CALIFORNL' WATER RESOURCES CONTRC 'OARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION ` ,o. COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1,NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLYCLO K ONE ITEM V2 INTERIM PERMIT F1 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 0 FACILITY/SITE NAME WHERE TANK IS INSTALLED: �l FARM TANK-YES❑ NO IC I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID N O B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: U, ()Q -Ab 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. I a A. 1 MOTOR VEHICLE FUEL 2 PETROLEUMC. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL ❑ B.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 D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: N All. TANK CONSTRUCTION MARK ONE 14M ONLY IN BOX A,B,C.8 D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 02SINGLEWAUED 4 SECONDARYCONTNNMENT ❑%OTHER 1 STEEUIRON 2 STAINLESS STEEL F-]3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE 6 POLYVINYLCHLORIDE F-1 7 ALUMINUM 6100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE ❑ 10 GALVANIZED STEEL [:]95 UNKNOWN %OTHER F-11 RUBBER UNE 2 ALKYD LINING F-13 EPDXY UNING 4 PHENOLIC LINING C. INTERIOR LINING [:] 5 GLASS LINING �UNUNED ❑%UNKNOWN ❑ B LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP galTAR OR ASPHALT ❑3VINYL WRAP ❑4 FIBERGLASS REINFORCE PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑%UNKNOWN ❑%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 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A L995 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 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS II/ P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE- P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE IST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3.WAS TANK VU.fD WITH SUBST R AINING IN GALLONS INER R ? YES [_ NO THIS FO HA BEEN COMPLETED UNDER PENALTY OFAERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# mI J0 113 o 10 1 o CURRENT LOQ AGENCY FACILITY # APMO% N�IET/ PHONE X WITH AREA CODE L C�fJ�F LU/ PERMIT NUMBER P ROT 7; TR ALD TE PERMITS RATION DATE CHECK# PERMIT AMOUNT SURCHA /A T. (/`/� FEE CODE RECEIPT• BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIE3wT A FACILITY/SITE APPLICATION, FORM 'A',UNLESS WORENT FORMA' HAS BEEN F.M. DATA PROCESSING COPY