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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM 04, TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIMPERMIT ❑ 4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED 9 FACILITY/SITE NAME WHERE TANK IS INSTALLED: Lf S' FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY IC A. OWNERS TANK ID# Tq,K B. MANUFACTURED BY: G4.K C. YEAR INSTALLED N. f< D. TANK CAPACITY IN GALLONS: p� A II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. I-► A. 1 MOT OR VEHICLE FUEL ❑ 2 PETROLEUM B C. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL ~ 1 PRODUCT ❑ ❑ [1]F-1 3 CHEMICAL PRODUCT ❑ 4 OIL 4 GASAHOL 5 JET FUEL 6 AVIATION GAB ❑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.N C.A.S.N: XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,&D A. TYPE OF ❑ 1 DOUBLEWALL M ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM M2 SINGIEWALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER STEEJIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MMATERIALF-15 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED SiEFL ❑95 UNKNOWN ❑98 OTHER C.INTERIOR ❑ I RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED Pf UNKNOWN ❑ISUNING MATERIAL COMPATIBLE WITH f00%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYEMLENE WRAP ❑2 TAR OR ASPHALT ❑3VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION [_ 91 NONE z UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A//U��6 CONCRETE A U 7 STEELCLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AICD/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 S IVISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3"DOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS 1 P S 6 PRECISION TESTING P S 7 PRESSURETESTING S 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 3, WAS TANK FILLED WITH NA SUBSTANCE REMAINING IN INERT MATERIAL? E_-]YES ❑NO /'r GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE � T LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# Q TANK ID# d 6010 � CURRENTg ENCY FACILITY IDN APPROVED BY NAME - PHONE#WITH AREA CODE "a5-PERMIT NUMBER PERMIT APPROVAL DA PERMIT EXPIRATION DATE CHECK PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(3-7-M) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED "DATA PROCESSING COPY