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STATE OF CALIFORNA WATER RESOURCES CONTP*gOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK (az TANK PERMIT APPLICATION INFORMATIONCOMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK.MAR EMY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION DTAN10 ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 7 PERMANENTLY CLOSED TANK ❑ -.e'6TANK REMOVED GI' FACILITY/SITE NAME WHERE TANK IS INSTALLED: N n G(pFARM TANK-YES I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 'v� ❑ NO 00 A. OWNERS TANK ID# I B. MANUFACTURED BY: 2i W C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 0 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A,1),IS NOT MARKED,COMPLETE ITEM D. A. 1;HAZARDOUS TOR VEHICLE FUEL ❑ 2 PETROLEUM B. C TUNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3MICAL PRODUCT ❑ 4 OIL �-1�FRODUC7 ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 ❑ 80 EMPTY ❑ WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM DBELOW) D. IF NOTTOR VEHICLE FUEL,ENTER NAME OF HAZARS SUBSTANCE STORED 8 C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ,[EtTSTEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS B. TANK ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLEFRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR 1 RUBBER LINED 2 ALKYO LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING ❑ LINING ❑ 5 GLASS LINING L?%-UNUNED ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES E] NO ta99 OTHER-95 IfN LIQ D. CORROSION ❑ 1 POLYETHLENE WRAP TAR OR ASPHALT ❑3 VINYL WRAP ❑ PROTECTION 4 FIBERGLASS REINFORCED PLASTIC ❑ 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 91 NONE A U 5 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE AN U PS UNKNOWN A U 99 OTHER A U f STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL ACU ] S 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 S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF -- SUBSTANCE REMAINING IN 3. WAS TANK FILLED WITH GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) - DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID N U /1 O 1 l V ONK IOD M CURRENT LOCAL AGENC C IT;L.IDN / Q + APPROV B`(NAME PHONE N WITH AREA CODE PERMIT NUMBER fl C /- Y PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIE BY A FACILITY/SITE APPLICATION, FORM 'A"UNLESS RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY