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STATE OF CALIFORNId WATER RESOURCES CONTROL BOARD FORM B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATIONeco FOR EACH TANK. _ Z MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYCLOSED TANK 4 AMENDED PERMIT ONE ITEM ❑2 INTERIM PERMIT ❑ ❑6 TEMPORARY TANK CLOSURE �TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: S' P �� L__/• N C.Y� FA RMTANK-YES❑ NOCF�l— 4► I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY CA) A. OWNERS TANK ID K N B. MANUFACTUREDBY: ERKINS OD C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS 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 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL �-� QY_l PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATIOj 5 HAZARDOUS ❑80 EMPTY ❑95UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BE D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# CAS.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM I:2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER B.TANK OL 11 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZEDSTEEL ❑95 UNKNOWN 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING F-13 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING G�j UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 10AMETHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP �2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED P T PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN OTHER vl'I 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 U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 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 U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 RSERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A(;U;;��6CONCRETE A U 7 STEEL CLAD W/FAP A U 6100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A Ub5 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 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF F-7 WASTANK FILLED WITH SUBSTANCE REMAINING INGALLONSINERT MATERIAL? E]YES E] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N I�AIGEN�Y N FACILITY ID B TANK ID N MI = L_J—LJ I d I O I 2 d l O lo CURRENT LOCAL AOENCY;71I YID N APPROVED BY NAME �/ PHONE N WITH AREA CODE EYG CJ 2 y PERMIT NUMBER PERMIT APP RO ALOATE PERMIT EXPIRATION DATE N CHECK# PERMITAMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: FORM B(6-29-66) THIS FORM MUST BE ACCOMPANI A FACILITYAITE APPLICATION, FORM 'A',UNLESS AZIIGENT FORMA' HAS BEEN FILED DATA PROCESSING COPY