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STATE OF CALIFORha WATER RESOURCES CONT BOARD sir. FORM' B'; UNDVKGROUND STORAGE TANK PR RAM `- TANK TANK PERMIT APPLICATION INFORMATION _ CO _ LETE A SEPARATE:FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. rw MARK ONLY lkfl NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED D r FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1411idqq, FARM TANK-YES❑ NO Lv I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 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(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL la) ❑ CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS HAZARDOUS ❑ 84 EMPTY ❑ 95 UNKNOWN WASTE ❑ 7 METHANOL �9 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# LAIAA C.A.S.#: xlll. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&0 A.TYPE OF ❑ I UBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEELIIRON ❑ 2 STAINLESS STEEL F-]3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS R✓rINF0RCE0 PLASTIC B.TANK ❑ MATERIAL 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ®7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR F-] I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING E]4 PHENOLIC LINING LINING ❑ 5 GLASS LINING R 6 UNLINED ❑95 UNKNOWN IS LINING MATERIAL COMPAT13LE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 PDLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑ 4 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 I SUCTION A U 2 PRESSURE 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEELPRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL Y7995 UNKNOWN A U 99 OTHER �1 LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. J P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 5 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS !/ P 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 99 OTHE VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1, ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED qUANTITY OF 3, WAS TAN FI -0 WITH SUB TA C MAINING IN INE T I YES NO GALLONS THIS FO H S BEEN COMPLETED UNDER PENAL O 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# TANK ID# [a] I I I I L 5T�d [d o I o:51 CURR_kNT LOCALAGENCY FACjgiry ID# APP V D at PHONE#WITH AREA CODE G6C 9947 PERMIT NUMBER P IT A-06FI01177 PERMIT EXPIRATION DATE I 197W CHECK# PERMIT AMOUNT SURC E T. FEE CODE RECEIPT# BY: ECRM B(3-7-aa) THIS FORM MUST BE ACCOMPANIEOWA FACILITY/SITE APPLICATION, FORM 'A,I]NIESSALOMPIENT FORM W HAS BEEN FILED DATA PROCESSING COPY