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STATE OF CALIFORRO WATER RESOURCES CONTR ' OARD FORM `B': UNDERGROUND STORAGE TANK PRRAM m'm TANK TANK PERMIT APPLICATION INFORMATION Q a COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT F915 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED // FACILITY/SITE NAME WHERE TANK IS INSTALLED: �6fi ) f/ FARM TANK-YES❑ NO ❑ O I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID N B. MANUFACTURED BY: C.YEAR INSTALLED U D. TANK CAPACITY IN GALLONS: 15110 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,poMPLETE ITEM D. M i Ejyl TOR CLE 2 LEADED 3 DIESEL A ❑3 CHOEMICAL PIRODUCTL ❑4 OIL PETROLEUM I-77/. PRODUCT C ❑ 4 GASAHOLD ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑BO EMPTY ❑95 UNKNOWN L❑J2 WASTE ❑ 7 MEFHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.R: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑�I DOUBLEWALLED F-13 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM Lb`SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER IL�gIy`STEELARON ❑ 2 STAINLESS STEEL F--] 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK hI 5 CONCRETE E]6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑81 W%METHANOL COMPATIBLE FRP MATERIAL L..� ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING n 4�PHENOUC LINING C. INTERIOR L f�'1/ LINING ❑5 GLASS ❑6 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHIENEWMP ❑ 2 TAR ORASPHALT ❑3 NYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMA ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 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 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 5 ALUMINUM A6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL t../ 5 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 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS_ P 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MOYYR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONSINERT MATERIAL? ❑YES E] 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY R FACILITY ID -j.� TANK ID# J C NT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE#WITH AREA CODE 'PERMIT plum-oll D / PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SUR CHARGE AMT. FEE CODE RECEIPT BY: FORM B(6-29-68) THIS FORM MUST BE ACCOMPANIE FACILITY/SITE APPLICATION, FORM 'A',UNLESS A C :.TNT FORMA' NAS BEEN FILED DATA PROCESSING COPY