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STATE OF CALIFORNI' WATER RESOURCESCONTRC- 90ARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL Nlj ONE ITEM F--12 INTERIM PERMIT ❑ 4 AMENDED PERMIT '' /❑ 6 TEMPORARY TANK CLOSURE ❑ S TANK REMOVED J FACILITY/SITE NAME WHERE TANK IS INSTALLED: 673' 7j' �, tt /ANned FARM TANK - YES ❑ NO Q I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID K B. MANUFACTURED BY: C. YEAR INSTALLED D TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF /A.11. IS MARKED. COMPLETE ITEM C. IF (A.11. IS NOT MARKED, COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 4 GASAH0 FUEL ❑ 6 AVIATION GAS ❑ 3 CHEMICAL PRODUCT OIL PRODUCT ❑I DET ❑ 5 HAZARDOUS ❑ 60 EMPTY ❑ 95 UNKNOWN ;21 WASTE ;2 ` WASTE ❑ 7 METHANOL 99 OTHER )DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED & C.A.S. N C.A.S. M oS_ III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D A. TYPE OF ❑ 1 DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER Ea-r-STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑ B 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING E26 UNLINED ❑ 95 UNKNOWN ,A ❑ IS LINING MATERIAL COMPATIBLE NTH 1010% METHANOL? ❑YES] NO OTHER 0. CORROSION ❑ I POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION w9tNONE UNKNOWN E] 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDE OUND, 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 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 A U 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 5ALUMINUM AIS CONCRETE A U ISTEELCLADW/FRP A U 8100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 195 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 8 1VISUAL CHECK P 8 2 INVENTORY RECONCILIATION/$ 3VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS NL - P S 6 PRECISION TESTING P S 7 PRESSURETESTING E x//8391 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE -511MAILUUAILLASI USEU(MU/YH) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH �A4? /. SUBSTANCE REMAjNING IN INERTgFlJ j ([Vj YES [:] NO GALLONS X, Y THIS FORM HAS BEEN C MPLETED UND�LTY OF PERJURY. AND TO THE BEST OF MY kNOWLEDGE, /9 TRUE AND CORRECT. APPLICANT'S NAME (PRINTED & SIGNATURE) I DATE OCAL AGENCY USE ONLY COUNTY # JURISDICTION # AGENCY # FACILITY ID # TANK ID * [z] == 4/ 01(o lo Wl CURRENT LOCAL AGENCY FACILITY IDN I APPROVED BY NAME 1 ( PHONE N WITH AREA CODE PERMIT PERMIT APPROVAL DATE CHECK# I PERMITAMOUNT I SURCHARGEAMT. I FEE CODE FORM B I6 -29 -eel THIS FORM MUST BE ACCOMPANItTi dY A FACILITY/SITE APPLICATION, FORM `A', UNLESS DATA PROCESSING COPY RECEIPT# I BY: FORMA' HAS BEEN FILED Z IU W N 00