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STATE OF CALIFORNifi WATER RESOURCES CONTRQ'ROARD FORM 'B': UNDGROUND STORAGE TANK PROGRAM _>--TANKTANK PERMIT APPLICATION INFORMATION TANK. COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH Z 10 MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ,//❑ 6 TEMPORARY -TANK 'CLOSURE ❑8 TANK REMOVED / w FACILITY/SITE NAME WHERE TANK IS INSTALLED: //0(—) , 4�// -C9YLJ 7� FARM TANK-YES❑ NO IV 00 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK 10# L2 3 7 B. MANUFACTURED BY: C. YEAR INSTALLED (N 0. TANK CAPACITY IN GALLONS: Q 1 11 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,9OMPLETE ITEM D. A. �1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. IV, UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT [j4 OIL RODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,j5ELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME HAZARDOUS HAZARDOUS SUBSTANCE STORED&C.A.S.#OF /4 C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,&D A.TYPE OF ❑ 1 DOUBLEWALLED ❑3 SINGLEWALLED WITH EXTERIORLINER ❑ 95 UNKNOWN '- SYSTEM ❑2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEBUIRON ❑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 E] 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑3 EPDXY UNING ❑4>NOUC UNING C. INTERIOR5 GLASS LINING ❑6 UNLINED 5 UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 V LWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A FABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A 1 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 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP 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 P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS aWI -✓✓T P S fi PRECISION TESTIN P S 7 PRESSURE TE STING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. I FORMATION ON TANK PERMANENTLY CLOSED IN PLACE F 3.WAS TANK FILLED WITH 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITV O SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES E] 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 COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY IO# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMITAMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIeU BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY