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STATE OF CALIFORNI1a WATER RESOURCES CONTROARD FORM B': UNDE GROUND STORAGE TANK PRO AM TANKTANK PERMIT APPLICATION INFORMATION .Z COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. IG MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 2-5-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: a p6/U I O)UFARM TANK-YES❑ 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CD A. OWNERS TANK ID 0 -1 B. MANUFACTURED BY: Un,7L.A�,.17ww� CIA)C.YEAR INSTALLED j I D. TANK CAPACITY IN GALLONS: 14 mo II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED e: DIESEL [:],3 CHEMICAL PRODUCT F-1 4 OIL PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL q 0 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEoAICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.k NA- C.A.S.k: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN �,! SYSTEMSIHOLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 6TEELIIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC( B.TANK �5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL Q 9.BRONZE ❑ 10 GALVANIZED STEELKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIORKNOWN LINING ❑ 5 GLASS UNING ❑6 UNLINED ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO �9 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAPTAR OR ASPHALT ❑3 VINYL WRAP ❑4 RBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A091 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 AUU95 UNKNOWN A U 99 OTHER A U ISTEEL/IRON A U 2 STAINLESSSTEEL A U 3POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE. A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEELCLAOW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U 5 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OF S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. !/ P S-j VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER M110NITORING WELLS L/ P S 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 OF 3,WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? 0 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 k JURISDICTION# AGENCY k FACILITY ID R TANK ID# 3E 6e CURRENT LOC AGENCY FACILITY ID k APPROVED BY NAME PHONE k WITH AREA CODE I 3 17 fi PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRA #DATE 1 CHECK# PERMIT AMOUNT SURCHARGE AMT FEE CODE RECEIPTk BY I FORM B(6-29-Be) THIS FORM MUST BE ACCOMPANII: A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A7§RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY