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STATE OF CALIFO IA WATER RESOURCES CO OL BOARD FORM `B': U ERGROUND STORAGE TANKROGRAM TANK TANK PERMIT APPLICATION INFORMATION =� COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ® a u, [FACILITY/SITE ARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 2 NE ITEM 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED /� NAME WHERE TANK IS INSTALLED: ^ l+✓ �. Nw o FARM TANK-YESz 60 ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY EOWNERS TANK ID# G� � B. MANUFACTURED BY: STALLED I— 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 E:�-YGNLEADED ❑2 LEADED ❑ 3 CHEMICAL PRODUCT ❑4 OIL ❑3 DIESEL � 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&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D C.A.S.�: A. TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑95 UNKNOWN ❑99 OTHER B.TANK 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP C. INTERIOR El 1 RUBBER LINED ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL E] 95 UNKNOWN ❑99 OTHER ❑2ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING LINING E]5 GLASS LINING ❑6 UNLINED ❑ , �}� ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? 95 UNKNOWN ❑YES ❑ NO 99 OTHER ��C D.CORROSION ❑ 1 POLYETHLENE 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 FA. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY (2 99 OTHER 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 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE AU 91 NONE 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 A �1 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. w'0'�'j tLP S 1 VISUA::CK P S 2 INVENTORY RECONCILIATION 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS S 6 PRECISESTING P S 7 PRESSURE TESTING P Al NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATEST USED(MO/YR) . I 2. ESTIMATED QUANTITY OF /� yQ SUBST C AINING IN 3. WAS TANK FILLED WITH GALLONS IN �ATERIAL? ❑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&SIG NATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# TFACILITY ID# TANK ID# Dij] = = I Mo Eo CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NA E PHONE#WITH AREA CODE PERMIT NUMBER 147—PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE'AM FEE CODE RECEIPT# BY: '911k jm� FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A F TY PPLICATION, FORM `A',UNLESS A CURREN1"r0RM9F HAS BEEN FILED A PROCESSING COPY