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STATE OF CALIFORNIA' WATER RESOURCES CONTROL ' )ARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - z MARK ONLY w NEW PERMIT ❑ 3 RENEWAL PERMIT S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANKREMOVED 16- N FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO 4bh N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK IDH 2. �j D B. MANUFACTURED BY I` C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM �B. C. ❑ 1 UNLEADED ❑ 2 LEADED �3 DIESEL F-13 CHEMICAL PRODUCT ❑4 OIL �I ' 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.H CA.S.H: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ' DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN 2 SYSTEM � SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER fes ' STEELARON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD WMBERGLASS REINFORCED PLASTIC B.TANK iiLL--JJ--77 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑81 W%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER F-1i RUBBER LINED E]2 ALKYD LINING F-13 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR LINING ❑5 CUSS LINING >r6 ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP Jam`TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 RBERGLASS 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 0 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION AV 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER AUO 1 STEEL/IRON A U 2 STAINLESSSTEEL 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 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 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. cF` (T/ P S I VISUAL CHECK POS 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 5 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 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 3, WAS TANK FILLED WITH SUBSTANCE REMAINING IN 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 H JURISDICTION R AGENCY H FACILITY ID H TANK ID H 31 = = lolol5 24 CURRENT LOOM AGENCY FACILITY IDN 1 APP D AME tm PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKM PERMiT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT R BY: FORM R(s-29-s8) THIS FORM MUST BE ACCOMPANIEDIIY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS AVARENT FORMA' HAS BEEN FILED DATA PROCESSING COPY