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STATE OF CALIFORNIA* WATER RESOURCES CONTROL�IQARD FORM 'B': UNDERGROUND PERMIIT APPLICATION ILNFORMAT�ION ., . TANK COMPLETE ASEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED d �- C FARMTANK-YES❑ NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: { _O I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIE A. OWNERS TANK ID N B. MANUFACTURED BY e r 11r;YDS '7 D. TANK CAPACITY IN GALLONS'. W G. YEAR INSTALLED :T CJ.) II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D.C.. . W B G ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL � A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑3 CHEMICAL PRODUCT ❑ 4 OIL �RODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BO EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.p'. HAZARDOUS SUBSTANCE STORED&C.A.S.N KIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D rYPE OF ❑ 1 DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN YSTEM I 2 SINGLEWALIED ❑4 SECONDARY CONTAINMENT ❑99 OTHER �STEEUAON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC ANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B IN%METHANOL COMPATIBLE FRP ATERIAL ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑9 BRONZE ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR SGUSS LINING G�14 UNLINED ❑95 UNKNOWN LINING ❑ ❑ IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? E]YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP ❑ 2 TARORASPHALT El VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U A U i STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C.MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 095 UNKNOWN A U 99 OTHER PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. V. LEAK DETECTION SYSTEM CIRCLE PFFOR PRIMARY,OR S FOR SECONDARY.A (.hh� P S 1 VISUAL CHECK �P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS XY J P S UNKNOWN P S 99 OTHER 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 i� VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3 WAS TANK FILLED WITH 2 ESTIMATED QUANTITY OF INERT MATERIAL' ❑YES ❑ NO 1. ESTIMATED DATE LAST USED(MO/VR) SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNODWLE DGE.IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# APPROVED BJ Y NAME lkv PHONE p WIT,AREA CODE C CURRENT LOC BE CY FAC LITY #I l �s r S 9 Y Il-. J / 6 PERMIT APPROVAL DAT PERMIT EXPIRATION DATE PERMIT NUMBER CNECKk PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT If BY: Aft FORM B 13-7-Bel THIS FORM MUST BE ACCOMP ..D BY A FACILITY/SDITATAAP PROCESSING ORMPA',UNL CURRENT FORMA' HAS BEEN FILED /