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STATE OF CALIFORNI% WATER RESOURCES CONTROARD FORM B': UNDEITOROUND STORAGE TANK PRO AM ; m" TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE NK REMOVED 09 N FACILITY/SITE NAME WHERE TANK IS INSTALLED: 2,110 j FARM TANK-YES❑ NO A. W 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY -4 A. OWNERS TANK IDN I B. MANUFACTURED BY: I AJ r,- 00 C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ULMOTOR VEHICLE FUEL ❑ 2 PETROLEUM 8. C. ❑ 1 UNLEADED ❑ 2 LEADED rx .3 DIESEL ❑ 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 8 C.A.S.# C.A.S.#, 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,S D A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 102 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER Er-1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER F-11 RUBBER LINED ❑ 2 ALKYD LINING F--13 EPDXY LINING ❑4 PHENOLIC UNING C.INTERIOR LINING ❑ 5 GLASS LINING 6 UNLINED 95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 990.. D. CORROSION ❑ 1 POLYETHLENEWRAP K2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A J SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNA U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE AC&15 UNKNOW A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A NKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRC E P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1VISUALCHECK (-P)S 2ESVENTORYRECONCILIATION P 8 3VADOSEWELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S ] PRS RETESTING P 8 91 NONE P S 95 UNKNOWN P 8 99 OTHER V1. 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 GALLONS INERT MATERIAL? ❑YES ❑ NO 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# m = = 101012-12- 10kj 101010111 CURRENTC�ENC FA�TY�# I APPROYCED�M J� .� PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE ,PERMIT EXPIRATION DATE �u( CHECK# PCRMITAMOUNT CHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88( THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A C T FORMA' HAS BEEN FILED