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STATE OF CALIFORN► 1 WATER RESOURCES CONTW BOARD FORM `B': UNDIDIGROUND STORAGE TANK PRQFRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 0 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT Tr5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED D FACILITY/SITE NAME WHERE TANK IS INSTALLED: Z C FARM TANK - YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERSTANKIDN 493B. MANUFACTUREDBY: C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL C. YEAR INSTALLED llq57D. TANK CAPACITY IN GALLONS: C)06 II. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. A. J�Jl MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT ❑ 4 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, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8, C.A.S. 0 C.A.S. R: /J rQ III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, &D A. TYPE OF ❑ 1 UBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLID -]4 SECONDARY CONTAINMENT ❑ 99 OTHER p:,m:NU, PRESSURE 1 STEEL/IfiON ❑ 2 STAINLESS STEEL ❑ 3 RBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ T ALUMINUM ❑ 8 100%METHANOLOOMPATIBLEFRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A F-11 RUBBER LINED ❑ 2 LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING UNLINED C. MATERIAL ❑ 95 UNKNOWN . - A, ' U 5 ALUMINUM ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? E] YES ❑ NO OTHER ��✓`J D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 OR ASPHALT ❑ 3 WNYLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. rIrim" lrvrvnmM l wn IAHULt A Ir Htl Y If UrvMcnOnVurvV, oV m v wrru,.wow 3, WAS TA FILLED WITH j I A SYSTEM TYPE A U `+SUCTION U p:,m:NU, PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION U SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM 6 CONCRETE A U 7 STEELCLAD W/FRP A U 6 10D% METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL 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. A T P 8 1 VISUALCHECK P 8 2 INVENTORY RECONCILIATION P �3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS /�- P S 6 PRECISION TE STING P S ]PRESSURE TESTING / 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF 3, WAS TA FILLED WITH j I SUBSTA C AINING IN IN T T IAL? E] YES NO ItlliA GALLONS _] THIS F( RM HASWEN COMPLETED UNDER PENALTY OFY'ERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND C( APPLICANT'S NAME (PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY RRECT. COUNTY N JURISDICTION k AGENCY M FACILITY ID S TANK ID 8 j I 1 D 1oC? 3 o> I o I o 3 CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME, 1, _ PHONE N WITH AREA CODE PERMIT APPROVAL DATE I PEAMITEXPIRATION DATE CHECK N I PERMIT AMOUNT I SURCHARGE ANT. I FEE CODE I RECEIPT 4 I BY: FORM B (6-29-86) THIS (FORM MUST BE TAFACILITY/SITE APPLICATION, FORM 'A', UNLESS NcORRENT FORM'A' HASBEENFILED DATA PROCESSING COPY 0