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STATE OF CALIFORNI � WATER RESOURCES CONTRC ~OARD FORM B': UNDERGROUND STORAGE TANK PROGRAM ' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - G MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK (� ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE �8 TANK REMOVED O FACILITY/SITE NAME WHERE TANK IS INSTALLED: 750 ^J FARM TANK-YES❑ NO00 ❑ N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY N A. OWNERS TANK ID# ul I B. MANUFACTURED BY: C. YEAR INSTALLED U.,114, 1 D. TANK CAPACITY IN GALLONS: S`;ro�. I 11. 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 PETROLEUMB. C. ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT WOIL 1 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 b.C.A.S.# C.A.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&0 A.TYPE OF ❑ DOUBLEWALLED ❑ 3 SINGLE WALLED WITH DRERIOR LINER ❑ 95 UNKNOWN li SYSTEM III��-Vyy-4yy2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT F-1 ❑99 OTHER IJ 1 STEEUIRON ❑2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE MATERIAL ❑6 POLYVINYLCHLORIDE 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER I ❑ I RUBBER LINED ❑2 ALKYD UNING ❑ 3 EPDXY LINING ❑4 HENOLIC UNING C. LIINT NGOR F-15 GLASS UNING ❑6 UNLINED WuNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 PDLYEfHLENEWRAP ❑�2 TARORASPHALT 3VINYL WRAP 4 FIBERGLASS REINFORCED PIASTIC PROTECTION ❑ 5 CATHODIC PROTECTION L-1O 91 NONE ❑95 UNKNOWN ❑ 99 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 91 NONE UNKNOWN A U 99 OTHER B. CONSTRUCTION A�UE LL 1 SINGLWAED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 N A UNKNOWN A U 99 OTHER (,�T I STEEUIRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 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 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUAWITV 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. APPLICANT'S NAME(PRINTED B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# T CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH ARM CODE 6"w ('— PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE �1 [CWCI(M PERMIT AMOUNT SURCHARGE AYT. FEE CODE RECEIPT BY: FORM R(6-29-66) THIS FORM MUST BE ACCO MPANIED`eY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEENFIFILED DATA PROCESSING COPY