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STATE OF CALIFORNWb WATER RESOURCES CONTRISOARD FORM `B': UNDE GROUND STORAGE TANK PRO RAM - = TANK TANK PERMIT APPLICATION INFORMATIONm ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. I Cry MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMITCHANGE OF INFORMATION ® 7 PERMANENTLY CLOS ANK ONE ITEM ❑ 2 INTERIM PERMIT F--] 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED61 N FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3 _ � ,oV FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY �� J A. OWNERS TANK ID 9 B. MANUFACTURED BY: € o C. YEAR INSTALLED LK D. TANK CAPACITY IN GALLONS: 67 II. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,96MPLETE ITEM D. A. M 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB, C 1 UNLEADED E] 2 LEADED 3 DIESEL F-] 3 CHEMICAL PRODUCT F-] 4 OIL j 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 8 C.A.S.N C.A.S.6: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ OUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEMu ` AGLEWALLED ❑4 SECONDARY CONTAINMENT ❑%OTHER 1 STEELIIRON F--]2 STAINLESS STEEL F-] 3 FIBERGLASS ❑4 STEEL CLAD W/FIBFRGLASS REINFORCED PLASTIC B.TANK F-] 5 CONCRETE ❑6 POLYVINYLCHLORIDE F-] 7 ALUMINUM ❑ 6 100%METHANOL COMPATIBLE FAP MATERIAL ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR F-] 1 RUBBER LINED ❑2 ALKYD LINING El EPDXY LINING PHENOLIC LINING LINING F--] 5 GLASS LINING F-]6 UNLINED 5 UNKNOWN ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES [:] NO THEA D.CORROSION F-11 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALTV95 INYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:] 5 CATHODIC PROTECTION E]91 NONE UNKNOWN E:]99 OTHER IV. PIPING INFORM ON 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 A 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 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 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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. S 1 VISUAL CHECKP S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 6 P S 6 PRECISION TESTIN S 7 PRESSURE TESTING P 8 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 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# m rid flql 1 h4 CURRENT LOCAL AGENCY FACILITY IDR pZ � APPROVED BY N PHONE MWfTH AREA CODE PERMIT NUMBER K PERMIT APPAOYAL DATE PERMIT EXPIRATION DATE VYCHECK N PERMIT AMOUNT 8URCHARGE AMT. PEE CODE ECEIPT R T-Y FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A L RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY