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STATE OF CALIFORNO WATER RESOURCES CONTRfWOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING I FORMATION FOR EACH TANK. Z MARK ONLY Fn NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 1 ❑ 7 PERMANENTLY CLOSED TA TANK ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED' Yl�� W FARM TANK-YES❑ NO (� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N A. OWNERS TANK ID# B. MANUFACTURED BYjs C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 6 O II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,C MPLETE ITEM D. A 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL IPRODUCT ❑ ❑ ❑6 AVIATION GAS 4 GASAHOL 5 JET FUEL ❑5 HAZARDOUS ❑'BO 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.q C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C.&D A. TYPE OF .pBJL�E WALLE�.D�� / �1GyfrVyAµEO WITH EXTEflIOfl LINER ❑95 UNKNOWN �Q SYSTEM SNGLE�IAQLED �T 4 SEL?OND WNTAINMENT ❑ 99 O1HER B.TANK STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 6100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 A LINING 3 EPDXYLINING 4 PHENOUCLINING C. INTERIOR ❑ ❑ LINING ❑5 GLASS UNING UNLINED ❑95 UNKNOWN ❑ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAO OR ASPHALT ❑3 VI LWAAP ❑4 RBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE U SUCTION A U 2 PRESSURE - U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 9/ NONE A U 95 UNKNOWN A U 99 OTHER A U STEEL/IRON A U 2 STAINLES§STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOVlN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. G✓-�O P S 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 1 P S 6 PRECISION TESTING S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. I FORMATION 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? L]YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 1,310 F50-7Fa OD 0 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL OAT PE MIT EXPIRATION DATE CHECK X PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT X BY; FORMB(6-29-8B) THIS FORM MUST BE ACCOMPANIE YA FACILITY/SITE APPLICATION, FORM 'A',UNLESS A URRENT FORMA' HASBEENFILED DATA PROCESSING COPY