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STATE OF CALIFORIV-1 WATER RESOURCES CONTE BOARD FORM'B': UNDERGROUND STORAGE TANK PRZrGRAMQO TANK TANK PERMIT APPLICATION INFORMATION CO LETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK.MARK ONLY I NEW PERMIT El3 RENEWAL PERMIT L CHANGE OF INFORMATION 7 PERMANENTLY CLOS N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED V FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK •YES ❑ NO I. TANK DESCRIPTION cnu.,e .... ,�..e ._...._.._.-.-. __ ____ III IV. — rr A. OWNERS TANK IDNJ93' G MANUFACTURED BY: C. YEAR INSTALLED 7—T D. TANK CAPACITY IN GALLONS: - I --•. -------------. --.-. --.-.. —'..r %a q, .a HU. MAHKED, COMPLETE ITEM D. A [Er1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑'KPRODUCT ❑ 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. N Al) s4C.A.S. x . . w.vn A.vna l null 11Vry MARK ONE ITEM ONLY IN BOY A -R -C -An A TYPE OF El JDOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER A U 95 UNKNOWN 1 STEER./IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS E]4 STEEL CLAD W/FIBERGLASS REINFORCEDPLASTIC B. TANK MATERIAL F-15 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 1D0% METHANOL COMPATIBLE FRP A U 95 UNKNOWN ❑ 9 BRONZE ❑ 10 GALVANIZEDSTEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR F-11 RUBBER LINED 1:12 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING r fi UNLINED A ❑ 95 UNKNOWN ACONCRETE ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL' ❑ YES ❑ NO rfr99 OTHER iv D. CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYLWRAP F� 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE Er95UNKNOWN ❑ 99 OTHER rIr11Nb IPNrunmia1 Pun CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE A SYSTEM TYPE A 1 SUCTION A U 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 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM ACONCRETE A U ]STEEL CLAD W/FRP A U e 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 1VISUAL CHECK 8 21NVENTORY RECONCILIATION P S 3VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P/�' S PRECISION TESTIN P 8 ]PRESSURE TE STING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DA E LAST USED (MO/YR) 2. ESTIMATED QUANTITY JFF TANK ID # 3. WAS T4 INK F FILLED WITH = = SUBSTANCE REM TNI IA tyEB# RIAL? ❑ YES ❑ NO APPROVED BY NAME„ _ J . / PHONE N WITH AREA CODE N GALLONS THIS F( M4 HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND C( APPLICANT'S NAME (PRINTED 8 SIGNATURE) DATE ONLY RRECT. COUNTY S JURISDICTION K AGENCY X FACILITY ID N TANK ID # ® = = 101O D6 103 CURREIN LOCAL AGENCY FACILITY IDN I APPROVED BY NAME„ _ J . / PHONE N WITH AREA CODE / �PERMIT NUMBER yrl'VI// CHECK N PERMIT AMOUNT FORM B (6-29-88) THIS FORM MUST SE DATE FEE CODE BY: 71 A FACILITY/SITE APPLICATION, FORM 'A', UNLESS 7AENT FORMA' HAS BEEN FILED DATA PROCESSING COPY Z 10 Gii N CD N 00