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STATE OF CALIFORNI% WATER RESOURCES CONTROMPARD FORM 'B': UNDERGROUND STORAGE TANK PRO AM TAN KTANK PERMIT APPLICATION INFORMATION ANK. o A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH T COMPLETE❑ 1 NEW ❑ SED o W PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY C O MARK ONLY n TEMPORARY TANK CLOS URE �fyg T/ANK REMOVED ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 `� 14-0 FACILITY/SITE NAME WHERE TANK IS INSTALLED: -7-760 W , `11" FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY CD A. OWNERS TANK ID# B. MANUFACTURED BY: /C/NS N C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: QQ Q II. TANK NTENTS 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 F-14 OIL 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 7D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: N HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,a D A.TYPE OF ❑ 1 D LE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER K15 STEEUIRON ❑ 2 STAINLESS STEEL F-] 3 FIBERGLASS ❑4 MEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE ❑fi POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑2/ILKYD LINING ❑3 EPDXY UNING ❑4 PHENOLIC UNING C. INTERIOR ❑5 GLASS UNING 6 UNUNED ❑ 95 UNKNOWN LINING ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑ AR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATJON 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 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U S ALUMINUM A ^6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPA71BLEFRP A U 9 GALVANIZED STEEL ±195 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. 4 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S fi PRECISION TESTING S ] PRESSURE TESTI NO P S 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 ❑ 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# JURISDICTION# AGENCY# FACILITY ID# TANKID# FoUER= I o001 CURRENT LOCAL AGENCYUCILITY ID N APPROVED BY NAME /O PHONE N WITH AREA CODE ECHECK NUMBER PERMIT APPROVAL DATE PERMIT EXPIA TION DATE113 /00 /(A/J_ I # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANI ,A FACILITY/SITE APPLICATION, FORM 'A',UNLESS ATMENT FORMA' HAS BEEN FILED DATA PROCESSING COPY