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STATE OF CALIFORNIA WATER RESOURCES CONTROL )ARD FORM 'B': UNDERMFIOUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - " Z 10 MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT K5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED N FACILITY/SITE NAME WHERE TANK IS INSTALLED: 6D > ' FARM TANK-YES❑ NO 411h 1. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY Q1 A. OWNERS TANK ID# _J)V t ^O B. MANUFACTURED BY: U,WI` C. YEARINSTALLED TY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. N11 UNLEADED ❑2 LEADED ❑ 3 DIESEL I ) ❑3 CHEMICAL PRODUCT ❑4 OIL Lr 1 PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL E]6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY F] 95 UNKNOWN E]2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOY0 I G J D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF Iy Ell (O HAZARDOUS SUBSTANCE STORED&C.A.S.# CAS.#: 111 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ I DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 02 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 SKEURON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE [_17 ALUMINUM F-]8100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING F-13 EPDXY UNING ❑ 4 PHENOLIC LINING C. INTERIOR LINING 5 GLASS LINING 6 UNLINED ❑95 UNKNOWN ❑ ❑ IS UNING MATERIAL COMPATIBLE WITH IW%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED KAM PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,130TH IF APPLICABLE A. SYSTEM TYPE A 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 AU 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 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A&95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR 8 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. O[ P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS J P S fi PRECISION TESTING 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 SUBSTANCE REMAINING IN GALLONSINEPT MATERIAL? [1]YES E] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRE'CsT. APPLICANT'S NAME(PRINTED S SIGNATURE) DATE J l LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 1010 (01c) I c 141 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY N E PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE jCHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: r Foam e�:az9ae:: THIS FORM MUST BE ACCOMPA I D BY AFACILITY/SITE APPLICATION, FORM 'A',UNLESMftRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY