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STATE OF CALIFORNItS WATER RESOURCES CONTROOPARD FORM `B': UNDE ROUND STORAGE TANK PRO AM N TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z I—I e G MARK ONLY If-�-%^EWPERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO$EBSANI( ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1t 7173 ) A-"4/ FARM TANK-YES❑ NO Cn I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY ~ N A. OWNERS TANK IDR DZ B. MANUFACTURED BY: t"lk/ —4 C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 2W a II. TANK C NTENTS IF(At),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE I7EM D.. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 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&C.A.S.R C.A.S. III. TANK CONSTRUCTION MARK ONE ITEM 6NLY IN BOX A,B,C,a D A.TYPE OF ❑ 1 UBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM IIIl 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑R 10096 METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 DLINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING 6 UNUNED ❑ry95 UNKNOWN/,. / [:] ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES F] NO U93 OTHER-"4w4 D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 RBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMAT ON CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE 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 Aly.,A 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 STEELARON 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 T STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 5 UNKNOWN A U 99 OTHER �. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P 3 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS =J 6 PRECIBION 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.ESTIMAlk DATE LAST USED(MO/YR) 2. ESTIMATED OUNTITY OF 3. WAS TANK ILL ED WITH NA SUBSTAN WING IN IN M AL? ❑YES [:] NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF P RJURY,AND TO THE BEST OF MY KNO E GE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# L.��12-- 1 = = I o I o I / I Z,=/ [T) lo 1-24 CURRENT LOCAL AGENCY FACILITY W# APPROVED BY NAME PHONE#WITH AREA CODE K ! tS6 PERMIT NUMBER PEIIMITA PROV DA PERMIT E% IRA I NCATE CHECK# PERMITAMOUNT RCHARGE AMT. FEE CODE RECEIPT#lAk FORM e(6 29-ee) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A MRENT FORMA HAS BEEN FILED DATA PROCESSING CCP,