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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM B': UNDERGROUND STORAGE TANK PROGRAM � a TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED W FACILITY/SITE NAME WHERE TANK IS INSTALLED: X Q S FARM TANK-YES❑ NOEV IN 1 ( ► 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 00A. OWNERS TANK ID k B. MANUFACTURED BY'. C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS'. II. TANK NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICALPRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL n 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL [yJ 9999 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF -//�- _ / �� HAZARDOUS SUBSTANCE STORED&C.A.S.q /l K.YIO ru CAS.P. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,&D A.TYPE OF ❑ 1y",BLE WALLED ❑ 3 SINGLEWALLED WITH E%TERIOR LINER El 95 UNKNOWN SYSTEM EV2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 1 Do%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2ALKYD LINING ❑ 3EPDXY LINING 4PENOLIC LINING C. INTERIOR F-15 GLASS LINING ❑6 UNLINED 5 LINING KNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO [:!?99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT ❑3 VI WRAP E] 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 A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 5 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U 91 NONE U 95 UNKNOWN A U 99 OTHER A U 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 S ALUMINUM A6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S J1 NONE P S 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY B JURISDICTION B AGENCY R FACILITY ID B TANK ID B 3z = 1010113 a i o I 002 CURRENT LOCAL ADEN T AGILITY IDX APPROVED BY NAME PHONE X WITH AREA CODE LGvt�l 25' PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 447 JCHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT X B1':�� YF1/JM (6-29-88) THIS FORM MUST BE ACCO MPANI BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A C RRENT FORMA' HAS BEEN FILED / f�^/ DATA PROCESSING COPY