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STATE OF CALIFORNIA WATER RESOURCES CONTROI "OARD FORM B': UNDEftROUND STORAGE TANK PRO ,SAM TANKTANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. O MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED N FACILITY/SITE NAME WHERE TANK IS INSTALLED: KI Q FARM TANK-YES❑ NO W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N 0D A. OWNERS TANKIDB QOt�Z B. MANUFACTURED BY: O YEAR INSTALLED [J 6 D. TANK CAPACITY IN GALLONS S II. TANK CONTENTS IF(A.I),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. �MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED LEADED ❑ 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑8 AVIATION GAS ❑ 5 HAZARDOUS 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑W OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENT R'NAME QF , HAZARDOUS SUBSTANCE STORED&C.A.S.q I C.A.S.N. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A B,C,8 D A. TYPE OF ❑ I DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM &02 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER IK1 STEEL/IRON E]2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM F-18180%MEFKANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER UNED ❑2 ALKYDUNING ❑3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR ❑ LINING 5 GLASS LINING t�t6 UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO OTHER D PROTECT ON ❑ 5 CATHODIC PROTECTION E WRAP ❑91TNONE ASPHALT ❑ 95 UNKNOWN ❑ 4 FIBERGLASS 99 OTHER REINFORCED PLASTIC ❑ ❑ o IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A W. 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U S ALUMINUM A U CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP - A U 9 GALVANIZED STEEL A 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 P 2 INVENTORY RECONCILIATION P 6 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P S 6 PRECISIONTESTING 8 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 DATE LAST USED(MONA) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONSINERT 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# JURISDICTION N AGENCY# FACILITY ID R TANK ID# ® / 1010 lo CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE N VA ol PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIFfATIOA DATE I CHECK M PERMIT AMOUNT T1 PURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED IYA FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY