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STATE OF CALIFORN14M WATER RESOURCES CONTROARD FORM `B': UNDEIRROUND STORAGE TANK PROAM-' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. P MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT DQ -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:yy �^�� FARM TANK - YES ❑ NO I. TANK DESCRIPTION rnmpi FTP All 1 ITFMR - IC I lhivuf1Y/u CA enc^.— A. OWNERS TANK ID # -> B. MANUFACTURED BY: I((✓�� C. YEAR INSTALLED ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS D. TANK CAPACITY IN GALLONS: ❑ 2 WASTE II. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D A. E F I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. '1UNLEADED ❑ 2 LEADED ❑ 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 & C.A.S. # C.A.S. #: All. 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 A �I�STEEUIRON E]2 STAINLESS STEEL F-]3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL F-15 CONCRETE ❑ 6 POLYVINYL CHLORIDE F-]7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP A ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING F--]3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING �6 UNLINED UNKNOWN ❑ 95 UNKNOWN U 99 OTHER ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP 2 AR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCI F A IF AROVF nprm INn ll IF I INf1FRnnoj imn DAT" IC ADDI IPADI A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH U 95 UNKNOWN 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 C. MATERIAL A U 5 ALUMINUM A U CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100% 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. Pp S 1 VISUAL CHECK U S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS Pk 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF3. WAS TANK FILLED WITH FACILITY ID # r A6 I A SUBSTANCE REMAINING IN INERT MATERIAL? 1:1 YES ❑ NO GALLONS PHONE # WITH AREA CODE 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 # r A6 I A TANK ID # ffFo-I CURRENT LOCAL AGCILITY ID # VE DW APPROVEDBYYyNAME�Q � LV — 9 tJ PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT E 1Dtf DATE CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT # BY: FORM B (3-7-88) 1 MIs FUNM MUST BE ACCOMPANIED ST-KFACILITY/SITE APPLICATION, FUHM 'A', UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY W iy F -L