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STATE OF CALIFORNI ^ WATER RESOURCES CONTRC iOARD FORM `B': UNDEWGROUND STORAGE TANK PROlnRAM � `�" TANK TANK PERMIT APPLICATION INFORMATION =` 'F'�.,;�''�3 COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ - MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ED K ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑)�� 6 �TEMPORARY TANK CLOSURE ❑8 TANK REMOVED Q>� FACILITY/SITE NAME WHERE TANK IS INSTALLED: 77 Z7j GL//�Z.Ti(-CL'b'� FARM TANK- VES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN — SO SPECIFY A. OWNERS TANK ID R O Z B. MANUFACTURED BY: C. YEAR INSTALLED A D. TANK CAPACITY IN GALLONS: . QQ II. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM 0. A. 01 MOTOR VEHICLE FUEL F—]2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED —] 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL5?11'PRODUCT SYSTEM ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS E]5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL Er 99 OTHER (DESCRIBE IN REM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF A /� to „e.(, / - Ll1.• HAZARDOUS SUBSTANCE STORED & C.A.S. R [ f, C.A.S. R: I — [Mb . � Z_ III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, 6 D IV. A. TYPE OF 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER A U 1 STEEL/IRDN ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGUSS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ S 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BPONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER U 2 STAINLESS STEEL U 6 CONCRETE U 95 UNKNOWN ❑ 1 RUBBER UNED E]2 ALKYOUNING ❑ 3 EPDXY UNING F-]4 PHENOLIC LINING C. LININGOR ❑ 5 GLASS LINING ©'8 UNUNED ❑ 95 UNKNOWN ❑ I$ UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑ YES ❑ NO EUM OTHER /if�/X✓ D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 WNYL WRAP [a-4'FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER YIF'INCi INhVHMAII N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE QUANTITY OF COUNTY P JURISDICTION R A SYSTEM TYPE TANK ID N 1 SUCTION A PRESSURE A U 3 GRAVITY A U 9/ NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER C. MATERIAL A U A U A U 1 STEELARON A 5 ALUMINUM A 9 GALVANIZED STEEL A U 2 STAINLESS STEEL U 6 CONCRETE U 95 UNKNOWN A U A U A U 3 POLYVINYL CHLORIDE(PVC) A U 7 STEELCLADW/FRP A U 99 OTHER (FIBERGLASS PIPE A U 91 NONE 8 100% METHANOL COMPATIBLE FRP Y. -LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. �) P S t VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOBE WELLS P S d ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S ]PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATE DATE LAST USED (MO/VR) 2. ESTIMATE QUANTITY OF COUNTY P JURISDICTION R 3. WAS TANK FIL D WITH TANK ID N I7 SUBST REMAINING IN INERT M T LA ❑ YES ❑ NO GALLONS JSJ r THII�F( 9M HAS BEEN COMPLETED UNDER PENALTY/OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND C APPLICANT'S NAME (PRINTED 8 SIGNATURE) DATE ERECT LOCAL AGENCY USE ONLY COUNTY P JURISDICTION R AGENCY N FACILITY ID # TANK ID N r 10 C) b CURRENT LOCAL AGENCY FACILITY ID F APPROVED BY NAME PHONE N WITH AREA CODE f/ 7 / Z� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK N 7ERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT k BY: FORM B (6-29-66) THIS FORM MUST BE ACCOMPANIEYBY A FACILITY/SITE APPLICATION, FORM 'A', UNLESS ko RRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY z 10 N 00 A 00