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STATE OF CALIFORN WATERP2SOURCESCONTR 30ARD FORM 'B': UNDIMGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION ( -°_ COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT E CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED I 1 FACILITY/SITE NAME WHERE TANK IS INSTALLED: aTa {�. TZTe FARM TANK-YES❑ NO (� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 0 A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(AA),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MqjOnEHICUE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODU ❑<GASAHOL ❑5 JET TF�FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN � ❑ 7 METHANOL ❑SB'OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF o euro 7G YF9 3 HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#. A 73 7,� III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXA,B,C,BD A.TYPE OF ❑ 1 DOU AILED ❑ 36114GLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM SINGLEWAL: ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 N ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK C ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑6100%METHANOL COMPATIBLE FRP MATERIAL -_ ❑ 9 BRONZE ❑ 10 GALVANIZE STEEL ❑ 95 UNKNOWN ❑99 OTHER F-1 1 RUBBER LINE ❑ 2 ALKYD LINING PDXY LINING ❑ 4 PHENOLIC UNING C. INTERIOR5 GLASS UNING 6 UNLINED ❑95 UNKNOWN LINING ❑ ❑ ❑ G LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TARORASPHALT ❑3 V WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U- 1 SUCTION A U 2 PRESSURE A 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 5 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 5ALUMINUM A U 6CONCRETE A U 7STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A'e)B5 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. ��T111 I P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS I lPPPP /� P 5 6 PRECISION TESTING P S 7 PRESSURE TESTING 91 NONE P S 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 E] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID M TANK ID# CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME / PHONE#WITH AREA CODE Z/1� /} 0 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EIRATION DA lrE CHECKM PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: / FORM a IS-zs-ee1 THIS FORM MUST BE ACCOMPANIEDIlIA FACILITY/SITE APPLICATION, FORM `A`,UNLESS A., RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY