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r STATE OF CALIFORNI& WATER RESOURCESCONTRCSOARD FORM 'B': UND GROUND STORAGE TANK PRO RAM TANK TANK PERMIT APPLICATION INFORMATION ° COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. -- MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT56 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS NK PERMIT ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDED TEMPORARY TANK CLOSURE ❑8 TANK REMOVED I If FACILITY/SITE NAME WHERE TANK IS INSTALLED: d !( � FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# I I B. MANUFACTURED BY: C. YEAR INSTALLED lqb6 D. TANK CAPACITY IN GALLONS: Q II. TANK CONTENTS IF(AA),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE M'D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL F-13 CHEMICAL PRODUCT ❑4 OIL I 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&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF Q/OUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER E]95 UNKNOWN SYSTEM LE 2 SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEELPRON ❑ 2 STAINLESSSTEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM B 10016 METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR F-] 1 RUBBERUNED ❑2 ALKYD LINING ❑3 EPDXY LINING [-]4 PHENOUC UNING LINING ❑ 5 GLASS LINING ❑6 UNLINED �95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO99OTHER D. CORROSION ❑ I POLYETHLENEWMP ❑ 2 TAR OR ASPHALT ❑ VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION [_]5 CATHODIC PROTECTION ❑ 91 NONE V95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, 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 Uq 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 i STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 RBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUMA 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL 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. 1 VISUAL CHECK 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 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 INERT MATERIAL? ❑YES ❑ NO 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# = = C '-2- ;; ouc 1 / CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE s x'60 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE z y/e CHECKN PERMIT AMOUNT &CHARGE AMT. FEE CODE EIPTN BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY