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STATE OF CALIFORNI& WATER RESOURCES CONTR OARD FORM B': UNDERGROUND STORAGE TANK PRO RAM TANK TANK PERMIT APPLICATION INFORMATIONm , COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION7 P"MANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT F-1LOSURE LU;4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CIL REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: kop /4 ' FARM TANK-YES❑ NOEV -� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# 0"c B. MANUFACTURED BY: UrvIC� C. YEAR INSTALLED 0,k)r. D. TANK CAPACITY IN GALLONS: jG 000 CA) II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. Q� A MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. E] 1 UNLEADED 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL K'�ARODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BD 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&Gk&# C.A.S.#: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINEflSUNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑810096 METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEELKNOWN ❑ 99 OTHER C. INTERIOR F-11 RUBBER LINED ❑ 2 ALKYO LINING F-] 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED ff� KNOWN ❑ ISLAND MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHIENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VI BAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 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 VL ov, QL-A--1 B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH AU 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 C. MATERIAL A U 5 ALUMINUM A }I,6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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. /��7�An/� P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS {I• P S 6 PRECISION TESTING P S 7 PRESSURE TESTING 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED 0/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL+ ❑YES ❑ NO GALLONS THIS FORM HAS dEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME _ PHONE#WITH AREA CODE 70 /s 6� PERMIT NUMBER PERMIT APPROVAL/DATE P MIT PIRATION TE [C7HECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT p BY: FORM B(3-7-BB) THIS FORM MUST BE ACCOMPANIE . FACILITY/SITE APPLICATION, FORM 'A',UNLESS A WENT FORMA' HAS BEEN FILED DATA PROCESSING COPY