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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM �q TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OFINFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE REMOVED a9 c-� N FACILITY/SITE NAME WHERE TANK IS INSTALLED: ca 1.J .yrk-Y-'1 FARM TANK-YES❑ NO 4► Q I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFYi✓ A. OWNERS TANK IO# S a, B. MANUFACTURED BY: LA Alc— a) C. YEARINSTALLED ( !w 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,� MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. i UNLEADED ❑2 LEADED ❑3 DIESEL F-13 CHEMICAL PRODUCT ❑ 4 OIL �RODUCT ❑ 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.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,E C,&D A.TYPE OF ❑�I DOUBLE WALLED F-] 3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM Ey IE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER _Erl'STEEL/IRON ❑2 STAINLESSSTEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/RBERGIASS REINFORCED PLASTIC B.TANK MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑B 100%METHANOL COMPATIBLEFRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RUBBERUNED ❑2 ALKYD UNING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING UNUNED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IW%METHANOL? ❑YES 0 ❑99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 RBERGUSSREINFORCEDPLAsnC PROTECTION ❑5 CATHODIC PROTECTION ie NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A(73 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 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AU 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 P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 3 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED 1.ESTIMATED DATE LAST USED M /YR) 2.ES"'IM ED QUI F' 3.WAS TANK FIL WITH �S�Alr REMYbWjf//7�� NALLON8 INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CO. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# 3 (F v TANK ID# ® I OU a I CA o= CURRENT LOCAL AGENCY FACILITY ID# I APPRO�D BY NAMCN PHONE N WITH AREA CODE PERMIT NUMBER rG fr"\' PERMIT APPROVAL DATE I PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT -URCMARGE ANT. FEE CODE N BY: -`" FORm e s-z9-eeI THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS �RE.CE.IPT NT FORMA' HAS BEEN FILED DATA PROCESSING COPY