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' STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 4`'` U FORM `B': UNDERGROUND STORAGE TANK PROGRAM x TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWININFORMATION FOR EACH TANK. . IU MARK ONLY El NEW PERMIT F-] 3 RENEWAL PERMIT 5 CHANGE OF INFORMAT4ON ❑7 PLRMANENTLY CLOSED K ONE ITEM ❑ 2 INTERIM PERMIT El AMENDED PERMIT. ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED i N FACILITY/SITE NAME WHERE TANK IS INSTALLED: 119 t4agoxA FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID III B. MANUFACTURED BY: S/� f C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: d 40 O II. TANK WNTENTS 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 [:j2LEADED ❑ 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL EV1PRODUCT ❑ 4 GASAHOL ❑ 5 JET,FUEL ❑ 6 AVIATION GAS 1:15 HAZARDOUS E] 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.# C.A.S.W Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D ; A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN' SYSTEM SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEELPRON ❑ 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL GLAD WIFiBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑8 10A METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER LINED 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PUENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED, ff; 5 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? [::]YES NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT n 3 WLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE [Y95 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 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 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE f C.MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 1069 METHANOL COMPATIBLE FRP i A U 9 GALVANIZED STEEL A 295 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. S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 1h P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P. S 95 UNKNOWN P S 99 OTHER V 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? ElYES E] NO - I THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY EPERMIT Y# JURISDICTION# AGENCY# FACILITY ID# TANK IO# q (� D [ 16) lo l AL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE VF-: D ER PERMIT PPROV LDA7 FERMI! EXPIRATION DATE PERMIT AMOUNT _SURCHARGE AMT. FEE CODE .-RECEIPT# BY: F r FORM B(6-29-aey THIS FORM MUST BE ACCOMPANIEDBY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORM`A' HAS BEEN FILED f DATA PROCESSING COPY