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STATE OF CALIFORNIA_, WATER RESOURCES CONTROfIARD FORM `B': UNDEPIGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING 1 TORMATION FOR EACH TANK. --_- MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TA 10 ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: O Q ' FARM TANK-YES❑ NO N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N A. OWNERS TANK ID# -2- 1 B. MANUFACTURED BY: LY K0 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: D DO 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 FKPRODUCT C. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWNSTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# IV6 CAS #: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ 1 MUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 5 UNKNOWN SYSTEM ❑'2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ , STEEL/IRON ❑ 2 STAINLESS STEEL FIBERGLASS 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR F-] I RUBBER LINED El2ALKYO LINING ❑3 EPDXY LINING E]4,9HENOUC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNUNED95 NKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IW%METHANOL? E]YES ❑ NO �THER U^ D.CORROSION ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3 V LWRAP F-] 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 5 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE Aip SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A L 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 A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEELU 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 1 VISUAL CHECK oP S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS �•f P PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 8 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 SUBSTANCE REMAINING IN GALLONS INERT MATERIAL' ❑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# AGENCY# FACILITY ID# TANK ID# m 16 1 O / I= c CURRENT AQENCY FACILI D N APPROVE BY NAME Q4 PHONE N WITH AREA CODE �` 1 / �/Q-A PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE Ail ` // CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT k BY: w FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED A FACILRY/SITE APPLICATION, FORM 'A',UNLESS A CWAENT FORM W HAS BEEN FILED DATA PROCESSING COPY