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STATE OF CALIFORNI& WATER RESOURCES CONTROOARD FORM `B': UNDE GROUND STORAGE TANK PROGRAM =� ' TANKTANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. °" Z 10 MARK ONLY 711 NEW PERMIT ❑ 3 RENEWAL PERMIT-. 5 CHANGE OF INFORMATION ❑7 PERMANENTLY OSE K ONE ITEM E:12 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE I, N FACILITY/SITE NAME WHERE TANK IS INSTALLED: C,611 MZ rot FARM TANK-YES❑ NO W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# 0-Zl I B. MANUFACTURED BY: C.YEAR INSTALLED ilia 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. [Erl UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL C.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.9F NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.4 11A #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,S.C,&D A.TYPE OF Q,11DOLIBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM I&12 31 GLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE 7 ALUMINUM ❑B ID0%METHANOLWMPATIBLEFRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER 1:11 RUBBERUNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR R ❑ 5 GLASS LINING �;6 UNUNEO ❑9 UNKNOWN r o,IAh [-] IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 09 OTHER ` D. CORROSION ❑ 1 POLYETHUENE WRAP ❑2 TAR OR ASPHALT ❑ 33 VINYL WRAP ❑ 4 F18ERGLASS REINFORCED PLASTIC PROTECTION [:] 5 CATHODIC PROTECTION ❑91 NONE Fk�UNKNOWN [:] 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER UCTIO S.CONSTRN 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 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(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 6 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A n5 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. P VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS l3 P S PRE,SIONTESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMAT DATE LAST USED(MO/YR) 2. ESTIMATED OUAPTITY OF 3.WAS TAN FILLED WITH SUBSTANCE A ING IN -GALLONS INERT E IAL? E]YES ❑ NO THIS F RM HAS BEEN COMPLETED UNDER PENALTY OF Pd4JURY,AND TO THE BEST OF MY KNOWLE GE IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY ID# APPRO ED BY NAMit Q PHONE#WITH AREA CODE 60 1 (t O PER IT NUMBER PERMIT APPROVAL DATE PERMIT EX (RATION DATE CHECK# PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIEM A FACILITY/SITE APPLICATION, FORM `A',UNLESS AZrRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY