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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM "- `= TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ _. z 1 NEW PERMIT 3RENEWALPERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK 10 MARK ONLY ❑ ❑ ❑ ❑ ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ®8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: C Q FARM TANK-YES❑ NO 011111111 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY —4 A. OWNERS TANK IDM Q B. MANUFACTURED BY: K C. YEAR INSTALLED K N ID. TANK CAPACITY IN GALLONS- nO II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A AI ' MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. §41 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑4 OIL1 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.M CAS,M: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,a D A. TYPE OF �❑y.�I 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN Id SYSTEM 2 SINGLE WADED ❑4 SECONDARY CONTAINMENT R 641, STEEL/IRON E32 STAINLESS STEEL ❑3 FI LASS? 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 Al1M�� ❑8 1 X%METHANOL COMPATIBLE FRP MATERIAL ❑99 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑( (�NG�R'U E0 ❑2 ALKYO LINING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING INED kl�UNKNOWN LINING IS LINING MATERIAL COMPATIBLEkINING WITH WI HIN%METHANOL? ❑YES ❑NO LRk OTHER D. CORROSION H 1 POLYETHLENEWRAP E]2'TAR OR ASPHALT F__] 3VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑ 91 NONE 4'95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SOCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER Be CONSTRUCTION A U 1 SINGLEWALLED A U 2DOFIBLEWALLEO A U 3LINED 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 FIBERGLASS Pike "A U 91 NONE C. MATERIAL A U 5 ALUMINUM A l�6 CONCRETE A 0 7 STEEI,CLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 5 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 8 1 VISUAL CHECK QP S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DA TE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH FFS� 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION M AGENCY M FACILITY ID M TANK ID M d 1 yb 1 101616) 111 CURRENT LOCAL AGENCY FACILITY ID x APPROVED BY NAME PHONE x WITH AREA CODE ENT2/ 'e-1 H l PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIR TIONO TE CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE x BY: FORM B(6 z9-66) THIS FORM MUST BE COMPANL'ztlY A FACILITY/SITE APPLICATION FORM 'A' UNLESS A COARENTF ORM'A' HAS BEEN FILED DATA PROCESSING,