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STATE OF CALIFORNIA - WATER RESOURCES CONTROL '"1ARD FORM `B': UNDERVROUND STORAGE TANK PROM TANK PERMIT APPLICATION INFORMATION y �~ TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I 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 TANK REMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: `jWJ—aS FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY •pOp A. OWNERS TANK ID It f B. MANUFACTURED BY: (,L / �+ C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: CA b6 [I. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT Q 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 ` ' f ^ r J HAZARDOUS SUBSTANCE STORED&C.A.S.# o f/L! 1 C.A.S.#: 0 5 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,&D A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ��TEELPRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPAUBLE RIP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR F-11 RUBBER LINED ❑2 ALKYD LINING F-] 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IW%METHANOL? ❑YES ❑ NO ❑ 99 OTHER O.CORROSION ❑ I POLYETHLENEWRAP ❑2T,AROR ASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC q PROTECTION ❑5 CATHODIC PROTECTION Ee"91 NONE ❑95 UNKNOWN ❑ 99 OTHER ' I IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE I A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A&2 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A iol SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER AU 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 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVAMZED STEEL A U 95 UNKNOWN A U 99 OTHER t V. LEAK DETECTION SYSTEM CIRCLE,P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P 5 7 PRESSURE TESTING 5 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. 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 1N 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. APPLICANTS NAME(PRINTED&SIGNATURE} DATE LOCAL AGENCY USE ONLY FCUR7RCYA JURISDICTION# AGENCYm- FACILITY ID# TANK ID# LzLe-A 10 10 AGENCY FACILITY ID# APPROVED BY ME �4/J PHONE N WITH AREA CODE AAM a l !U ►J�. PERMIT APPROVAL DATE ERMIT EXPIRATION DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE .RECEIPT N BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANItc.dY A FACILITY/SITE PPLICATIBN, FORM `A',UNLESS AURRENT FORM'A' HAS BEEN FILER DATA PROCESSING COPY