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r -,..� +r-, +Ftp-w�---c;,.&"..�" rHw.,:.-..•..*�,.�.,.�,yy�„,,.,��0'°"'r ,..-,� _ ,• STATE OF CALIFORNI WATER RESOURCES CONTRqftOARD FORM `B': UND GROUND STORAGE TANK PRO RAM TANK / TANK PERMIT APPLICATION INFORMATION ff '" -' IL \—`COMPLETE A SEPARATE FORM WITH THE FOLLOWIN,q INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 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: 6%Z N I4jhA g4oe L162N FARM TANK - YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN — SO SPECIFY A. OWNERS TANK ID # B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 2 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 Z2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 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. # C.A.S. #: III. TANK CONSTRUZTION MARK ONE ITEM ONLY IN BOX A, B, C, a D IV. A. TYPE OF 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER U 3 GRAVITY A U 91 NONE STEEL/IRON ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK P5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 4 FIBERGLASS PIPE A U 91 NONE 8 100% METHANOL COMPATIBLE FRP ❑ 1 RUBBER LINED E]2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 HENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED CHECK # 95 UNKNOWN AMT. ff ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO 99 THER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER ririIYL7 IIYrVI'SIVIA 1 IVPI GIHGLL A IFA GHUUNU, U IF UNUtHUHUUNU, BOTH IF APPLICABLE 3. WAS TANK FILLED WITH A. SYSTEM TYPE A U 1, SUCTION A 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION U SINGLE WALLED A U 2 DOUBLE WALLED A U LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER C. MATERIAL A U A U A U 1 STEEL/IRON A 5 ALUMINUM A 9 GALVANIZED STEEL A U 2 STAINLESS STEEL U 6 CONCRETE U 95 UNKNOWN A A A U 3 POLYVINYL CHLORIDE (PVC) CA�j U 7 STEEL CLAD W/FRP A U U 99 OTHER 4 FIBERGLASS PIPE A U 91 NONE 8 100% METHANOL COMPATIBLE FRP LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. �I P S P S 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 6 PRECISION 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. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH FACILITY ID # SUBSTANCE REMAINING IN INERT MATERIAL? [:]YES [:]NO 1 1 1 11 GALLONS LL F/T/--p 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 # FACILITY ID # TANK ID # EK4 1 1 11 EII I LL F/T/--p I I I ls-1 CURRENT LOCAL AGENCY FACILITY ID # APPROVED BY NAME PHONE # WITH AREA CODE roy 4"3 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPI ATION 6ATE 11! 1 0 CHECK # PERMIT AMOUNTi AMT. ff ICHARGE FEE CODE RECEIPT # BY: FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, F014M 'A', UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY 1d