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STATE OF CALIFOINRAGE IA WATER RESOURCES COOL BOARD FORM 'B': U DERGROUND STOTANK ROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ,❑ 7 PPERMANENTLYCLO ,o ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE Y X TANK REMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: d �, FARM TANK-YES❑ NO .&22126 I. TANK DESCRIPTIONCOMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 1 Ip A. OWNERS TANK ID# O B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK gONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. —4 A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL u PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ M 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 A. TYPE OF ❑ 1 UBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER E]95 UNKNOWN SYSTEMjpNGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER Pi 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS E]4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑6100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER UNED ❑2 AWDLINING ❑3 EPDXYUNING ❑4 PHENOLIC UNING LINING ❑5 GLASS LINING UNLINED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%MEMANOL? ❑YES ❑NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 _,T6R OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATAON 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 99 OTHER B.CONSTRUCTION A64 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH 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 C. MATERIAL A 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 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. Nb P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S I PRECISION TESTING P 5 7 PRESSURETESTING P S 1 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LA81 UgED(MO/YR) 2. ESTIMATED OUANTI �QF 3.WAS TANK FILL WITH ,� / SUBSTANC RE A Id[jEINERT M E 7 ❑YES E] NO Y v �/I GGG N GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF 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# o a 171 1 oo 10 111 CURRENT LOCAL AGENCY FACILITY ID# APP ED A PHONE#WITH AREA CODE PERMITNUMBER PERMIT APPROVAL D PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SUR CHARGE AMT. FEE CODE RECEIPTM By; FORM B(3-7-88) THIS FORM MUST BE ACCOMPANI A FACILITY/SITE APPLICATION, FORM 'A',UNLESS ATRRENT FORMA' HAS BEEN FILED , DATA PROCESSING COPY