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STATE OF CALIFORNIt WATER RESOURCES CONTRO' BOARD FORM'B': UNDERGROUND STORAGE TANK PRO gAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Feo5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C ONE ITEM F—]2 INTERIM PERMIT F-14 AMENDED PERMIT [:]6 TEMPORARY TANK CLOSURE [:]J 8 TANK REMOVE / 2. FACILITY/SITE NAME WHERE TANK IS INSTALLED: / .3 3 y I!c� aAAlN/ " FARM TANK - YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS -IF UNKNOWN -SO SPECIFY A. OWNERS TANKID# 0/ 1 B. MANUFACTURED BY: ❑ 3 CHEMICAL PRODUCT F-]4 OIL C. YEAR INSTALLED j4,t./6(j D. TANK CAPACITY IN GALLONS: Q II. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.11. IS NOT MARKED. COMPLETE ITEM D- A. Er1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ELC. ❑ 1 UNLEADED ❑ 2 LEADED Efl'3 DIESEL ❑ 3 CHEMICAL PRODUCT F-]4 OIL P' 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. # A C.A.S. #' 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D IV A TYPE OF ❑ 1_ DOUBLE WAILED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER A 2r1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 IDB% METHANOL GOMPATIBLEFRP A U 95 UNKNOWN ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A U 2 STAINLESSSTEEL CONCRETE U 5 UNKNOWN F-]1 RUBBER LINED ❑ 2 ALKYD LINING F-13 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING �6 UNLINED ❑ 95 UNKNOWN, ❑(SEINING MATERIAL COMPATIBLEWITH 100%METHANOL? E] YES ❑NO �99 OTHER ✓� 'v D. CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE P1 95 UNKNOWN ❑ 99 OTHER Y1P'INLi INhVHMI�JUN CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE 4 ELECTRONIC MONITOR P A SYSTEM TYPE P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING � 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 C. MATERIAL A A A U 1 STEEL/IRON U 5 ALUMINUM U 9 GALVANIZED STEEL A U 2 STAINLESSSTEEL CONCRETE U 5 UNKNOWN A A A U 3 POLYVINYL CHLORIDE( PVC) A U U 7 STEEL CLAD W/FRP A U U 99 OTHER 4 FIBERGLASS PIPE A U 91 NONE 8 100% METHANOL COMPATIBLE FRP 7Q� V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. r VI. P S 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION �q1 3VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING � 7] S 91 NONE P 8 95 UNKNOWN P S 99 OTHER INFORMATION ON TANK PERMANENTL CLOSED IN PLACE RIALS ❑ YES E] NO I SURCHARGEAMT. 1. ESTIMATEDATE LAST USED (MO/YR) 2. ESTIMATED QUI OF CU ENT LOCAL AGENCY FACILITY ID N 3. WAS TAN FILLED WITH ITN AREA CODE 'IA ISUBSTANCE MAINING IN PERMIT E% (RATION DATEf INERT RIALS ❑ YES E] NO I SURCHARGEAMT. Alln GALLONS THIS F( RM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLELJGE, IS TRUE AND C( APPLICANT'S NAME (PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY 4RECT. COUNTY# JURISDICTION# ®I AGENCY# FACILITY ID# U b i TANKID# I ello 16 CU ENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME I ITN AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT E% (RATION DATEf CHECK N PERMIT AMOUNT I SURCHARGEAMT. FEECODE RECEIPT# BY: FORM B (6-29-88) IMI# FUMM MU51 BE ACGUMPANIEU BY A FACILITT/SITE APPLICATION, FUHM -A', UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY 10