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STATE OF CALIFORt: 4 WATER RESOURCES CONT" 'L BOARD FORM'B': UNDERGROUND STORAGE TANK PR6GRAM TANK TANK PERMIT APPLICATION INFORMATION COf LETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. N MARK ONLY Frl NEW PERMIT ❑ 3 RENEWAL PERMIT 1 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY gLQSE&fA4K ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVE 6� FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK -YES ❑ NO Rr 1. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID # 0-7,- B. MANUFACTURED BY: / C. YEAR INSTALLED 1d1 �1 '? D. TANK CAPACITY IN GALLONS'. I QO II. TANK CONTENTS IF (A.11. IS MARKED. COMPLETE ITEM C. IF (A.11. IS NOT MARKED- COMPLETE ITEM D_ A. 1 MOTOR VEHICLE FUEL F-]2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED MESE F]3 CHEMICAL PRODUCT ❑ 4 OIL �1 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. # CA S, #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, a D A. TYPE OF ❑ 1 OUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER U 3 GRAVITY A U 91 NONE pf 1 STEEL/IRON ❑ 2 STAINLESS STEEL F-]3 FIBERGLASS F-]4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE r-17 ALUMINUM ❑ B 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING E]4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING y ®6 UNLINED A ❑ 95 UNKNOWy _ � , 8 100% METHANOL COMPATIBLE FRP ❑ ISUNING MATERIAL COMPATIBLE WITH 100% METHANOL? E] YES E]NO OTHER ((/HAL_/ D. CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONEIff 95 UNKNOWN ❑ 99 OTHER IV. PIPING IN RMA N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE AGENCY # FACILITY ID # b 145 1 z I= 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 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 F)BERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A� 5 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 5.1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P 8 3VADOSE 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 TELAST USED(MO/YR) 2. ESTIMA QUANTITY OF 3. WAST NK FILLED WITH SU $ILiEMAINING IN E TERIAL? ❑ YES ❑ NO 14 ��y GALLONS THIS F04M HAS BEEN COMPLETED UNDER PFNAI TY DF PFAII IRY ANn Tn THF RFRT nF AAV WwOwl EDGE Ic TRUE AAun CO--" APPLICANT'S NAME (PRINTED & SIGNATURE) DATE COUNTY R JURISDICTION # AGENCY # FACILITY ID # b 145 1 z I= TANK ID # IDG 6 CURRENT LOCAL AGENCY FACILITY IDN I _ APPRpVED BY NAME L A PHON�#WITN AREA CODE PERMIT CHECK# I PERMITAMOUNT I SURCHAkGEAMT( I FEE CODE I RECEIPT# I BY: 'ORM B S-29-88) THIS FORM MUST BE ACCOMPANIIIII A FACILITY/SITE APPLICATION. FORM 'A'. UNLESS AMRENT FORMA' NAR RFFM CII FD DATA PROCESSING COPY 10