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STATE OF CALIFORN' WATER RESOURCES CONTR BOARD FORM 'B': UNDERGROUND STORAGE TANK PR(YbRAM TANK TANK PERMIT APPLICATION INFORMATION CO LETE A SEPARATE FORM WI I M THE FOLLOWING iNFORMA I wO FOR EACH i A MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT [-j 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY L T NK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVE 6I FACILITY/SITE NAME WHERE TANK IS INSTALLED: zvoo FARM TANK -YES ❑ NO 1 T'AAIK'FIF:CCDIDTInN COYnIFTFAII ITFMS_IF UNKNOWN -SO SPECIFY A OWNERS TANK IDN O B. MANUFACTURED BY: C YEAR INSTALLED �'/ 7 3 D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS n rnuel FTF ITFu c IF a 11 IR NOT MARKED. COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑2 P ROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICALPRODUCT OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ /5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS E]80 EMPTY [-]95 UNKNOWN ❑ 99 OTHER 7 METHANOL 1- 1 99 OTHER (DESCRIBE 1142TPWD,BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED & C.A.S. N C.A.S. N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B. C, A D A TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM [e2 SINGLE WALED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER A U 1 STEBUIRON ❑ 2 STAINLESS STEEL ❑ 3 RBERGLASS ❑ 45TEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 100%METHANOLCOMPATIBLEFRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER U 2 STAINLESSSTEEL F-11 RUBBER UNED ❑ 2 ALKYD LINING F-13 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING UNLINED [:],PKNOWN , ' 7 STEELCLADW/FRP A U E] IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL? YES ❑ NO 99 OTHER (�j4A' D. CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHDDIC PROTECTION ❑ 91 NONE M-9'UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDE UND, BO TN IF APPLICABLE 3. WAS TANK•F LED WITH TANK ID N A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B CONSTRUCTION A U i 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 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 7 STEELCLADW/FRP A U B 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A U 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 1 VISUAL CHECK 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 6 5 GROUND WATER MONITORING WELLS PeS PRECISION TESTING P 8 7 PRESSURETESTING P S 91 NONE P 6 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMA DDATE LAST USED IMO/YR) 2. ESTIMATE UANTITY OF 3. WAS TANK•F LED WITH TANK ID N SUBSTA MAINING IN INE M T L? ❑ YES ❑ NO GALLONS THIST R LVGAL RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND C( APPLICANT'S NAME (PRINTED & SIGNATURE) DATE RRECT. COUNTY N JURISDICTION N AGENCY N FACILITY ID 8 TANK ID N IJ I�I 16101ob lo CURRENT LOCAL AGENCY FACILITY ID I APPR4VED BY NAME - 9A QA PHONE N WITH AREA CODE IPERMIT NUMBER ( I PFRINITAPFft0VALPAJEj_ I PERMIT EXPIRATION DATE I CHECK N I PERMIT AMOUNT I SURCHARGE AM,T. I FEE CODE I RECEIPT* I BY: -.- — .,., - wit FODu MIIRT RF APCnMDANIF A FACII ITV/SITF APPLICATION- FORM 'A'. UNLESS A EMAENT FORMA' HAS BEEN FILED DATA PROCESSING COPY Z 10 W N CD IV co