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STATE OF CALIFORNft NK WATER RESOURCES CONTR*ARD FORM 'B': UND GROUND STORAGE TAPR AM In mo TANKTANK PERMIT APPLICATION INFORMATION Z COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 10 MARK ONLY ❑ I NEW PERMIT F-1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION7 P RMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT E] 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED w FACILITY/SITE NAME WHERE TANK IS INSTALLED: V FARM TANK-YES❑ NO W N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY co A. OWNERS TANK ID# 77 271 B. MANUFACTURED BY: a4vAEl C. YEAR INSTALLED ' D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL F-� 2 PETROLEUM B. C. 1 UNLEADED 2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT OIL [:] 1 PRODUCT ❑ 4 GASAHOL 5 AT FUEL 6 AVIATION GAS 5 HAZARDOUS BO EMPTY [:]95 UNKNOWN P"�ASTE 7 METHANOL Q 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.# C.A.S.#: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑�0 BLE WALLED �3 SINGLE WALLED WITH EXTERIOR LINER �95 UNKNOWN SYSTEM III 2 SNGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER 1 STEELMON 2 Is STEEL ❑3 FIBERGLASS [:]4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE F-16 POLYVINYLCHLORIDE r-17 ALUMINUM ❑ 6100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE E] 10 GALVANIZED STEEL [--1 95 UNKNOWN [:]99 OTHER 1 RUBBERUNED Q 2 A DUNING 3 EPDXY LINING 4 PHENOLIC LINING C. INTERIORN5 GLASS LINING fi UNLINED 95 NKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES D NO �THER �/ D.CORROSION ❑ I POLYETHLENE WRAP [:]2 TAR OR ASPHALT F-�3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODICPROTECTION L2<1 NONE ❑ 95 UNKNOWN 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U (FUNDER 4 OUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER S.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER AU 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 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. )e P S 1 VISUALCHECK P S 2 1NVENTOPY RECONCILIATION S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING `91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1 ES IMATED DATE LAST USED(MO/YR) 2. ESTIM TED QUANTITY OF 3.WAS NK FILLED WITH / SUB ANCE REMAINING IN GALLONS IN ATERIAL? E]YES 0 NO THIS FORM HAS BEEN COMPLETED UNDER PENAL OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY �� 'CCOO�UTY#NTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 10101 I-.a/--J�L_I O CURRENT LOCAL bAGENCY FACILITY IDN 1APPROV BY NAME PHONE N WITH AREA CODE It NLd PERM) NUMBEfl PERMIT APPROVAL DATE PERMIT EKPIRATI N DA CHECKN PERMIT AMOUNT URCHARGE AMT. FEECODECEIPTN BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY