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STATE OF CALIFORPW WATER RESOURCES CONT BOARD a FORM `B': UNDERGROUND STORAGE TANK PRI GRAM TANK TANK PERMIT APPLICATION N ORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWINFORMATION FOR EACH TANK. Z to MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 08 TANK REMOVED W FACILITY/SITE NAME WHERE TANK IS INSTALLED: ktAPAWFARM TANK-VES❑ NO ki F-6 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY OD A. OWNERS TANK ID# RAJ IKALOW&C B. MANUFACTURED BY: Kt4 kAZ0I4.1Aj N C. YEAR INSTALLED t 1 D. TANK CAPACITY IN GALLONS: 1 1 OD 11. 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 ❑ 2 LEADED ❑3 DIESEL F-13 CHEMICAL PRODUCT E]4 OIL wov F-11 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS [-] 5 HAZARDOUS E]80 EMPTY F&]95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF ,A HAZARDOUS SUBSTANCE STORED 8 C.A.S.# ✓L k C.A.S.#: u�/ 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,!D A. TYPE OF ❑ I DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ®95 UNKNOWN SYSTEM D ❑4 SECONDARY COMAINMENT ❑99 OTHER 5T ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL !N ❑99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING �—❑�3 EPDXYLINING ❑4 PHENOUC LINING LINING ❑5 GLASS LINING ❑fi UNLINED ©95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLEWITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHtENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ©95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U i SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U i SINGLEWALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE AQ96 UNKNOWN A U 99 OTHER A U / STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A(b 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 S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE QQ) 8 95 UNKNOWN P S 99 OTHEfl VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? FLYES [L:] NO v O D W HI' GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE c E cC I cj-6 - sq LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# MEI o0 -k � vi 10 10 1 aEl— CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE N PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK 7ERMIT AMOUNTI SURCHARGEAMT, FEE CODE RECEIPT# BY: 4 FORM B(8-29-88) THIS FORM MUST BE ACCOMPANIED i A FACILITY/SITE APPLICATION, FORM A',UNLESS AWCURRENT FORMA' HAS BEEN FILED L DATA PROCESSING COPY