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STATE OF CALIFORNIA* WATER RESOURCES CONTROLVARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM '.„ TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEWPERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: / e FARM TANK-YES❑ NO Z 1. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 A. OWNERS TANK ID# &,1 n B. MANUFACTURED BY: C. YEAR INSTALLED 96, D. TANK CAPACITY IN GALLONS: �$ w 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. O A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ i UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ED4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS 08 EMPTY ❑95 UNKNOWN ©IWASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF u I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ StlNhM01YITLe SYSTEM ❑2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1EEL/ STIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4MEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXY LINING ❑4 PHBKIUC UNING LINING ❑5 GLASS UNING ❑6 UNLINED ro/95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? E]YES E] NO D9 OTHER 0. CORROSION ❑ I POLYETHLfNE WRAP ❑2 TARORASPHALT ❑3 VINYL WRAP �4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODICPROTECTION ❑91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A jo 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED p dU 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) AUO4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FAP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 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 S 1 VISUAL CHECK Po 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS 08 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED IMO/YR) 2. ESTIMATED QUANTITY OF F 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO GALLONS 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 IDM o (gI cgs oDo / CURRENT LOCALAGENCYFAC ITYIDp APPROVED BY NAM PHONE#WITH AREA CODE a � 9 _719DO PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGEAMT. FEECODE RECEIPT# BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CrhRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY