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STATE OF CALIFORNI0 WATER RESOURCES CONTROARD FORM 'B': UNDE ROUND STORAGE TANK PRO AM TANK PERMIT APPLICATION INFORMATION TANK °- COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z MARK ONLY ❑ 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 1:1 7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ®8 TANK REMOVED O N FACILITY/SITE NAME WHERE TANK IS INSTALLED: C III I-ow FARM TANK-YES❑ NO A I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 00 A. OWNERS TANK IDA Q B. MANUFACTURED BY'. u C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS'. 00 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. �j A. �1 MOTOR VEHICLE FUEL � 2 PETROLEUM B. C. ❑ 1 UNLEADED E] 2 LEADED Lm DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT 0 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 C.A.S.#'. HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,1110 A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 4 2 SINGLEWALLED F-1 4 SECONDARY CONTAINMENT [:]99 OTHER AL1 STEEUIRON Ej 2 STAINLESS STEEL F-1 3 FIBERGLASS F-1 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE 6 POLYVINYL CHLORIDE F-� 7 ALUMINUM ❑B 10D%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE 10 GALVANIZED STEEL F] 95 UNKNOWN F-] 99 OTHER 1 RUBBER LINED 2 ALKYD LINING F--] 3 EPDXY LINING ��4^,PHENOLIC LINING LINING C. INTERIOR F--] 5 GLASS LINING F-] 6 UNLINED �UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? 0 YES [::] NO E:] 99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT F�3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE EK5 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A(bj 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 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 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A(995 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 S 1 VISUAL CHECK P 9 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING 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. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# ® = = 101011131-3 lel I I dO 10 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE G# PERMIT NUMBER PERMIT APPROVAL DATE PERMIT E%PIRA ON DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT• BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIEVORWA FACILITY/SITE APPLICATION, FORM `A',UNLESS A RENT FORMA' HAS BEEN FILED 4 DATA PROCESSING COPY