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v -lap STATE OF CALIFORN �"� WATER RESOURCES CONTR(— OARD s.�;.°: FORM `B': UND GROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION 4. CO PLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY Vf 1 NEW PERMIT ❑ 3 RENEWAL PERMIT [:)5 CHANGE OF INFORMATION F-1 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE El 8 TANK REMOVED ol FACILITY/SITE NAME WHERE TANK IS INSTALLED: �p`�- ' I y C>r� �� FARM TANK-YES❑ NO lz 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY to A. OWNERS TANK ID# tj Dr- B. MANUFACTURED BY: f C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Ls�Q(] Jbb II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. IV A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM BEo'_l C. E] 1 UNLEADED ❑ 2 LEADED C� DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL PRODUCT E] 4 GASAHOL [:1 5 JET FUEL [::] 6 AVIATION GAS i ❑5 HAZARDOUS [:] 80 EMPTY ❑ 95 UNKNOWN E]2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME Of I HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF F-] 1 DOUBLE WALLED 7 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM Eq-2-'SINGLE WALLED ❑ 4 SECONDARYOONTAINMENT 99 OTHER 1 STEELIIRON ❑ 2 STAINLESS STEEL F-1 3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%MFTHANOLCOMPATIBLE FRP MATERIAL El 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER 1 RUBBER UNED ❑ 2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING C.LININ INTERIOR 5 GLOSS LINING E 6-'UNE 95 UNKNOWN LINING � E-�'""" 0 ISUNINGMATERIAL COMPATIBLE NTH 1w%METHANOL? YES [-] NO 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP [:] 2 TSAR OR ASPHALT F-13 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODICPROTECTION ff 1 NONE 95 UNKNOWN Ej 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A 01 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEELIIRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE IPVC) A U 4 FIBFRGLASS PIPE 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 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 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 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? 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 M JURISDICTION M AGENCY# FACILITY IDM TANK ID# ld0hj31 <7n0 CURRENT LOCAL AGENCY FACILITY ID k APPR Y BY NAM PHONE k WITH AREA CODE C �� PERMIT NUMBER PERMIT APPRD L DATE ERMIT EXPI,ATION DATE 8z CHECK k PERMIT AMOUNT SURCHARG AMT. FEE CODE RECEIPT k BY: K 1 —4 FORM B 13-7-88) THIS FORM MUST BE ACCOMPA Y A FACILITYISITE APPLICATION, FORM `A',UNLESS,__JRRENT FORM`A' HAS BEEN FILED DATA PROCESSING COPY /