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STATE OF CALIFORNI WATER RESOURCES CONTR( BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. __ z MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK I O ONE ITEM [-] 2 INTERIM PERMIT ❑4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED di N FACILITY/SITE NAME WHERE TANK IS INSTALLED:3),OO 15 �(L srfko FARM TANK-YES❑ NO ❑ 41116 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 0 A. OWNERS TANK ID# ' IB. MANUFACTURED BY: QKNN C. YEARINSTALLED wl u I D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS 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 ❑ 2 LEADED ®3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL �. 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑60 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.# CA.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER EL95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER F-11 STEEL/IRON ❑ 2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL F-15 CONCRETE E]6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 5K95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER UNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING L114 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNUNED 95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODICPROTECRON ❑91 NONE 95 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 5 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 95 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 U S CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AO95 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 I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P & 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE8 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE CeluIL&uTSWftitY 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING INGALLONS 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID 8 TANK ID# 3 = = 10161- = a o6 CURRENT LOCAL AGENCY FACILITY ID x APPROVED BY NAME PHONE#WITH AREA CODE V h' c—*. ( y PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK x PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT It BY: FORM B(6-29-ee) THIS FORM MUST BE ACCOMPANIEVBY A FACILITY/SRE APPLICATION, FORM'A',UNLESS MRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY