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STATE OF CALIFORN WATER RESOURCES CONTR OARD 5f=`. .F W. FORM'B': UND GROUND STORAGE TANK PRRAM 'm TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. o'" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT L=J 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY? ANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVEl f J? FACILITY/SITE NAME WHERE TANK IS INSTALLED: -ZS-/ Al, FARM TANK - YES NO I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID # B. MANUFACTURED BY: C. YEAR INSTALLED 4e2 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. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 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 & C.A.S. # A C.A.S. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D A. TYPE OF 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM U 2 SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER B. CONSTRUCTION STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL [:j 95 UNKNOWN ❑ 99 OTHER 4 FIBERGLASS PIPE A U 91 NONE F-11 RUBBER LINED F-12 ALKYD LINING ❑ 3 EPDXY LINING F-]4 PHENOLIC LINING C. INTERIOR LINING F-]5 GLASS LINING 6 UNLINED 8 100% METHANOL COMPATIBLE FRP ❑ 95 UNKNOWN A U ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO �9 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP Ef-2-TARORASPHALT ❑ 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 Ul SUCTION A Ufi 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 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 A6 CONCRETE A U 7 STEEL CLADW/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U5 UNKNOWN A U 99 OTHER __--k LEAK DETECTION S!ITEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK Ex 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. IllidORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DA E LAST USED (MO/YR) 2. ESTIMATED UANTITY OF FACILITY ID # 016 1 17 / 1 3. WAS TA K FILLED WITH T/ CURRENT LOCAL �FACILITY ID # pAGENCY APPROVEDj3Y NA ,/ 74 SUBST MAINING IN GALLONS IN ERIAL? ❑ 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 & SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # Um I I I J. AGENCY # FT I I FACILITY ID # 016 1 17 / 1 TANK ID # 210 16 1 � I CURRENT LOCAL �FACILITY ID # pAGENCY APPROVEDj3Y NA ,/ 74 PHONE #WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT # BY: FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIEDW A FACILITY/SITE APPLICATION, FORM 'A', UNLESS A (.RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY PV S