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STATE OF CALIFORNI,^ WATER RESOURCES CONTRO' 90ARD FORM 'B': LINDEWGROLIND STORAGE TANK PRO-JRAM TANK TANK PERMIT APPLICATION INFORMATION ° COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED-1-14K ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED Fafl FACILITY/SITE NAME WHERE TANK IS INSTALLED: QQ Q ,( FARM TANK-YES❑ IN W W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I'a A. OWNERS TANK IDK I B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: �Q II. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL VIPRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL 6 AVIATION GAS ❑5 HAZARDOUS 80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL 99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.K C.A.S.K: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A TYPE OF. DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM [2 F-1 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE ❑6 POLYVINYLCHLORIDE LJ-<MINUM ❑ 8100%METHANOL COMPATIBLEFRP ❑ MATERIAL LJIrI--]IQ/9 BRONZE ❑10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER ❑ 1 RUBBER UNED 2 ALKYD LINING 3 EPDXY LINING n 4 ENOUC LINING C.INTERIOR LTJI/ LINING ❑ 5 GLASS LINING 6 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALTTWE WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION [—]5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMAT ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A IUJ 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A JL96 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 A&M UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A fhb CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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. f'y S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS 6 PRECISION TESTING 8 7 PRESSURETESTING P 8 91 NONE P 8 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 GALLONS 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN 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 K JURISDICTION K AGENCY K FACILITY ID K TANK ID N CURRENT LOCAL AGENCY FACILITY ID ILQ�/� APPROVED BY NAME,? PHONE N WITH AREA CODE PERMITNUMBER `C PERMIT APPROVAL DATE ///P/VEER,MMIT EXPIRATION DATE 16116CKM PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTN BY: FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A ...n NT FORMA' HAS BEEN FILED DATA PROCESSING COPY