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STATE OF CALIFORNI WATER RESOURCES CONTRC Z;OARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM (az TANK TANK PERMIT APPLICATION INFORMATIONCOMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. I MARK ONLY F-1I NEW PERMIT [-] 3 RENEWAL PERMIT 2�'5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDT iyl ONE ITEM ❑ 2 INTERIM PERMIT El AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 955 FARM TANK-YES❑ NO� A I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY C A. OWNERS TANK ID N I \1[.O5 LtUK MANUFACTURED 8V: K C. YEAR INSTALLED i 9? I D. TANK CAPACITY IN GALLONS: O II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF IRA),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. G ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL KI PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 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&CAS.N CA S.q: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLEWALLEDMTH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 02 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER . IRJ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS RFJNFORCED PLASTIC B.TANK 5 CONCRETE 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METWWOLCOMPATIRLEFRP MATERIAL ❑9 BRONZE ❑ I0 GALVANIZED STEEL �95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNED ❑2 UKYD UNING ❑ 3 EPDXY LINING 4 PHENOLIC UNING C. INTERIOR I�y ❑ 95 UNKNOWN LINING ❑ 5 GLASS UNING x1 6 UNLINED ❑ IS UNINGMATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3WNYL VMA ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 995 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A OU 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 0 95 UNKNOWN A U 99 OTHER A U 1 STEELIRON 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 6 CONCRETE A U 7 STEEL CLAD W/FAP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A OU 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 I VISUAL CHECK V S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS OP 6 PRECISION TESTING P 3 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 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 SUBSTANCE REMAINING IN (UILLONB INERT MATERIAL? ❑YES E] NO 1 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. SIIS/�� APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE [ 111 LOCAL AGENCY USE ONLY l COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N ZE E:= lololi lbl,5161 = CURB NT LOCAL AGENCY FACILITY ID 0 APPROVED BY NAY PHONE N WRN AREA CODE 9- PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKN PERMITAMOUNT EURCNARGE AMT.` FEE CODE RECEIPTt BY: FORMS(6-29-88) THIS FORM MUST BE ACCOMP BY A FACILRY/SrtE APPLICATK)N, FORM 'A',UNLESS' RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY