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STATE OF CALIFORNIf WATER RESOURCES CONTRO' "OARD FORM 'B': UNDERGROUND STORAGE TANK PRO*AM TANK bl TANK PERMIT APPLICATION INFORMATION � ` COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - z 0 CJ MARK ONLY ❑PERMIT F-] 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION E:] 7 PERMANENTLY CLO NK ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE' E:]8 TANK REMOVE 0 FACILITY/SITE NAME WHERE TANK IS INSTALLED: G FS KN� / (� rj�/y� FARM TANK-YES❑ NO GJ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY O A. OWNERS TANK ID# f B. MANUFACTURED BY: al C. YEAR INSTALLED I I D. TANK CAPACITY IN GALLONS: Q II. TANK 9ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A V1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. E] 1 UNLEADED E] 2 LEADED 3 DIESEL F__] 3 CHEMICAL PRODUCT ❑ 4 OIL 1 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&C A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ UBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK F-]F-] 5 CONCRETE ❑6 POLYVINYLCHLORIDE D17 UMINUM ED 100%METHANOL COMPATIBLE FRP 11 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER C. INTERIOR F__] 1 RUBBER LINED E:] 2 ALKYD LINING E] n 3 EPDXY LINING 4AENOUC LINING LINING ❑ E:] ru`7-0) ',,UNKNOWN GLASS LINING 6 UNLINED NKNOWN E] IS LINING MATERIAL COMPATIBLEWITH 100%METHANOL? ❑YES E:] NO �THER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT n 3AL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMAT ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND.BOTH IF APPLICABLE A SYSTEM TYPE A U 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 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 C. MATERIAL A U SAIUMINUM A CONCRETE A U 7STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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. 1 VISUAL CHECK P 8 INVENTORY RECONCILIATION P S 3VADOSE WELLS P S 4ELECTRO11C MONITOR P S 5 GROUND WATER MONITORING WELLS DP 6 PRECISION TESTING P S ] 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 GALLONS INERT MATERIAL? E:]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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANKID# o30 I6 10 00 / CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAM.1 PHONE N WITH AREA CODE � a PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ICHECK# PERMIT AMOUNT SURCHARGE AMT. ' I�FEE CODE RECEIPT BY: FORM B(6-29-BB) THIS FORM MUST BE ACCOMPA FACILITY/SITE APPLICATION, FORM 'A',UNLESIi,,,,IIIIIIIItNT FORMA' HAS BEEN FILED DATA PROCESSING COPY