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STATE OF CALIFORNIE WATER RESOURCES CONTROI )ARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM (oz TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 1 MARK ONLY ❑1 NEW PERMIT ❑ 3 RENEWALPERMIT ZC5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED JANK 7M ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVEM 0 1 FACILITY/SITE NAME WHERE TANK IS INSTALLED: /j ' FARM TANK-YES❑rNO,'49 4b. I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# -01S B. MANUFACTURED BY UUK C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS 96�0 p II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM 0. IZ �I I A. ol MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL DKi PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BO 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.N C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM X2SINGLEWALLED ❑4 SECONDARYOONTAINMENT 99 OTHER -01 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR F-] 1 RUBBBRUNED ❑2 ALKYD UNING F-] 3 EPDXY LINING ❑4 PHENOUC LINING LINING ❑ 5 GLASS UNING X6 UNLINED ❑ 95 UNKNOWN ❑IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2TAR OR ASPHALT ❑ 3 VIM'LWTUP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODICPROTEmON ❑91 NONE 995 UNKNOWN ❑%OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE AU 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A& 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FAP A U 9 GALVANIZEDSTEEL A O 95 UNKNOWN A U 99 OTHER _ V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR E'FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. ^ P S 1 VISUAL CHECK 6 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS OP 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 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 SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT slls��g APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# o I I0 a s CURR NT LOCAL AGENCY FACILITY ID# APPROVED BY NAM PHONE M WITH AREA CODE � 4 PERMIT UMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CMECKk PERMff AMOUNT SURCHARGEAMT.., FEE CODE RECEIPT# BY: lINNE FORMB(6-29-88) THIS FORM MUST BE ACCOMPA1 BYAFACLITY/SREAPPUCATION, FORM IN',UN RRENT FORMA' HASBEENFILED DATA PROCESSING COPY