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STATE OF CALIFORD WATER RESOURCES CONT BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 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: .4.c/�2- FARM TANK - YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID # B. /" B. MANUFACTURED BY: u k - •�1/PRODUCT C. YEAR INSTALLED r D. TANK CAPACITY IN GALLONS: ❑ 7 METHANOL 99 OTHER (DESCRIBE IN ITEM D, BELOW) Q(,'f HAZARDOUS SUBSTANCE STORED & C.A.S. # C.A.S. #: ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE II. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, CONkWLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. /" C• 1 UNLEADED ❑ 2 LEADED E]3 DIESEL ❑ 3 CHEMICAL PRODUCT F-]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. # C.A.S. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D /' IV. A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER L& ff 95 UNKNOWN SYSTEM ❑ 2 SI WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER U 1 SINGLE WALLED A U -2DOUBLE WALLED LV 1 STEEL/IRON Spbj T SS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FAP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 8 100% METHANOL COMPATIBLE FRP F-]1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHE IC LINING C. INTERIOR LINING F-15 GLASS LINING F-]6 UNLINED UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALTV95VUNKN WRAPEl4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑ 91 NONE OWN 99 OTHER PIPING INFORMATION CIRCLE A IF ABOVE C�D, 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 NWN U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U -2DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE U 95 UNKNOWN U 99 OTHER PERMIT APPROVAL DATE 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 FRP A U 9 GALVANIZED STEE 95 UNKNO A U 99 OTHER V. LEAK DETECTION Sy.P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S INVENTORY RE 1 VISUAL CHECK 'P CO P S 3 VADOSE WELLS P S9 KNOWN NITOR P S 5 GROUNDWATER MONITORING WELLS / P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 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 # LLI�l41 I ld SUBSTANCE REMAINING IN INERT MATERIAL? ❑ YES ❑ NO GALLONS PHONE # WITH AREA CODE 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 # I AGENCY # El I I FACILITY ID # LLI�l41 I ld TANK ID # Lo lo lcda]- CURRENT LOCAL AGENCY FACILITY ID # Ian+/ / R APPROVED BY NAME PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODERECEIPT # I ll BY: FORM B (6-29-88) THIS FORM MUST BE ACCOMPANOTY A FACILITY/SITE APPLICATION, FORM 'A', UNLESS AMRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY o