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.w. NPa- +RN1'4:4P! .ly. _ 1 ._M_ ..ATL ■ STATE OF CALIFORNIA WATER RESOURCES CONTFIC FORM B': UND ROUND STORAGE TANK PRO AM w' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 1 G MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION L] 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ,L(, ANANK REMOVED Q N FACILITY/SITE NAME WHERE TANK IS INSTALLED: � FARM TANK-VES❑ NO ❑ 1s CD I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N A. OWNERS TANK IDN IEf 03-2aj' B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: lo.nnO II. TANK CO,NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COIM--ETE ITEM D. A. MOTOR VEHICLE FUEL ❑2 PETROLEUMC. C UNLEADED G212 LEADED E] 3 DIESEL F-13 CHEMICAL PRODUCT F--] B.4 OIL 1 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 8 C.A.S.# WIL C.A.S.#: AJ/A Z 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,6 D A TYPE OF ❑ I W WALLED ❑3 SINGLE WALLED WITH EK9ERIOR LINER ❑ 95 UNKNOWN SYSTEMSINGLE ALLBD ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER STEEL/IRDN ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑818096 METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ 1 RUBBFAUNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ IC LINING C. INTERIOR LINING ❑5 GLASS LINING ❑6 UNLINED E379UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYEM ENEWRAP ❑2TAR OR ASPHALT ❑3VI P ❑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 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION 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 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 A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 95 UNKNOWN A U 99 OTHER o V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUALCHECK CP,)S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS 42 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 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 C AAR ETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID N TANK ID N ol 6 1 J 1 ov 1 o CURRENT LOCAL ENCY FACILITY ID# APPROVED BY AME PHONE N WITH AREA CODE nm-l- l PERMIT NUMBER PERMIT APPROVAL DATE PE ITEXPIRATI DATE FECKN— PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTN BY: FORMB(6-29-BB) THIS FORM MUST BE ACCOIAPAN YAFACIUTY/SITE APPLICATION, FORM 'A',UNLESS RRENT FORMA' HASBEENFILED DATA PROCESSING COPY