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STATE OF CALIFORI.X WATER RESOURCES CONT BOARD FORM FBF: UNDERGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION .yI TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING ORMATION FOR EACH TANK. Z I 10 MARK ONLY : ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY K ONE ITEM2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK flEMOV �i W FACILITY/SITE NAME WHERE TANK IS INSTALLED: 65� $YSv1 e FARM TANK-YES NO ❑ N 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID B B. MANUFACTURED BY: C.YEAR INSTALLED uk D. TANK CAPACITY IN GALLONS: IL TANK CONTENTS IF(AT),18 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ A OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL E]6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY E]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 A C.A.S.E CAS.p: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C,a D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑A SECONDUFVCOWAINMENT ❑99 OTHER ❑ 1 STEEURON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑A STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC S.TANK ❑ S CONDIETE ❑e POLYVINYLCHLORDE ❑ 7 ALUMINUM ❑B 1009E METHANOL COMPATIBLE FRP MATERIAL . ❑ 9 BIgIRE ❑ 10 GALVANIZED STEEL ❑95 UNNNOYIN ❑99 OTHER C.INTERIOR ❑ I RIMERUNED ❑2 MOD UNING ❑ 3 EPDXYUNING ❑ 1 PHENDUCUNING LINING ❑ 5 GMLIMNG ❑6 UNLINED ❑ 95 UNKNOWN ❑ B L NNG MATERAL COMPATIBLE WITH LOOM METHANOL? ❑YES ❑NO ❑ 99 OTHER D.CORROSION ❑ I POLYETHLENEWNAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑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 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 U 95 UNKNOWN A U W OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%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 SE CIRCLED. P { 1 VISUAL CHECK P { 2 INVENTORY RECONCILIATION P B 3 VADOSE WELLS P B A ELECTRONIC MONITOR P B 5 GROUND WATER MONITORING WELLS P { 6 PRECISION TESTING P { 7 PRESSURE TESTING P B 91 NONE P B 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED GUANTITY OfGALLONi 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY B JURISDICTION B AGENCY E FACILITY ID B TANK IO B CURRENT LOCAL AOENCY F CI A OIN — ,„ APPROVED BY NAME PHONE 0 WITH AREA CODE PERMIT NUMBER EJ��IJ PERMIT APPROVAL DATE ►ERMIT EXPIRATION DATE LCLPERYIT AYOUN7 BURCHARGEAMT. FEE CODE RECEIPT/ BY: L✓ -VY',/ V.J FORM B(6-2B-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED nAl. oonrec esu.- rnn..