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" STATE OF CALIFORNIA WATER RESOURCES CONTRO- ? t?OAR '1 I iLutdcr Ion FORM `B': UNDE1GROUND STORAGE TANK PRdghAM kEmavEQ TANK TANK PERMIT APPLICATION INFORMATION P COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PFRMANENTLY CTANK �! ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT Ll6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE 6 FACILITY/SITE NAME WHERE TANK IS INSTALLED: r((jL ? T(Q FARM TANK-YES NO g -, 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID A ((m�� yu B. MANUFACTURED BY: / Lg ,.� C. YEAR INSTALLED / D. TANK CAPACITY IN GALLONS: O PO IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1j 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ' ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1f 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D.BEL OVA D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED d C.A.S.# C.A.S.# 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,&D A. TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH DLTERIOR UNER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ MMATERIAL5 CONCRETE ❑6 POLYVINYL CHLORIDE F-1ALUMINUM ❑8 IDA METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER G INTERIOR F-] 1 RUBBER UNED ❑2 ALKYD LINING ❑ 3 EPDXY UNWG ❑ 4JKNDUC UNING LINING ❑5 GLASSUNING ❑6 UNLINED 95 mm" ❑ ISLINING MATERIAL COMPATIBLE WITH 100%MET}{A110L" ❑YES ❑ Np ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAA OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS 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 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 A U 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 A U 1 STEEL/IRON A U 2 STAINLESS STEEL 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 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRA 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. P 6 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS I P 5 5 PRECISION TESTING P 3 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 UTHbH VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1 ESTIMATED DATE LAST USED(MO/YR) 2 ESTIMATED DUANTITY OF!7. - . .�r�-_ 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 E SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY N FACILITY ID A 'TANK ID k I LO I d 17 CURRENT LOCAL AGENCY FACILITY IDA APPROVED BY NAME PHONE A WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE7�� CHECK A PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT A BY: -"q-90 cr FORM B(6-29-as) THIS FORM MUST BE ACCOMPAN Y A FACILITY/SITE APPLICATION. FORM 'A'.UNLESS A I.JRRFNT ;:nRM v- NAC RFFAI CII FI1