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STATE OF CALIFORNWI WATER RESOURCES CONTR ((�lz FORM `B': UND GROUND STORAGE TANK PR R �✓ TANK PERMIT APPLICATION INFORMATI TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FO EACf'�pl��JtQ.1 1988 0 a Ip MARK ONLY EW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION [i`.j 11 , YEf�yIA�NE�.T-Y,C TA ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE pry ,8;TA��AE141�1NED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# c14tB. MANUFACTURED BY: C. YEAR INSTALLED .•ry D. TANK CAPACITY IN GALLONS: CJC� 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. [B'-1—UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OILi 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.i A C.A.S.#: A44 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF U3"1DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL 3 FIBERGLASS ❑4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 6 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING 3 EPDXY LINING F-14 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100116 METHANOL? YES ❑ NO ❑ 99 OTHER ERECT N ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT ❑ 3 VINYLWRAP 4 FIBERGLASS REINFORCED PLASTIC ON ❑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 cu. 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 ACU 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&14 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 FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER �- LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS S 6 PRECISION TESTING 7 PRESSURE TESTING P S 91 NONE S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 41 1. ESTIMA�E DATE LAST I4SEIJ(MO/YR) 2. ESTIMATED QUA TITY OF 1 3.WAS TANK FI ED WITH SUBSTANC R ING IN INERT MAT A ? ❑YES [:] NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PE JURY,AND TO THE BEST OF MY KNOWLEDG ,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE �1 � — LOCAL AGENCY USE ONLY C[f�lUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# I I 1 -1 EI I 1 1 131- 1 -31 ,51 ,51 1611-1 0 CURRENT L AGENCY FACILITY 10# APPROVED BY AAME PHONE S WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PER IT EXPIRATION DATE CHECK# PERMIT AMOUNT CHARGE AMT. FEE CODE IMPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIEDB A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CUR ENT FORMA' HAS BEEN FILED DATA PROCESSING COPY, '