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STATE OF CALIFORP& WATER RESOURCES CONT BOARD ; FORM 'B': UN ERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION _ COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK, FI MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ®8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 22191 S. FARM TANK-YES❑ NO ® .p I. TANKOESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CA A. OWNERS TANK ID# ,e B. MANUFACTURED BY: LL C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: O s0 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A. Z.1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ I UNLEADED ❑ 2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL L1 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.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,13,C,8 D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM RiVINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ I STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.MATERIAL ❑5 CONCRETE ❑6 POLYVINYL ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL [i4-95 UNKNOWN ❑ 99 OTHER ❑ C. INTERIOR I RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXYLINING E]4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED P�lm UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%MFTHANOL? ❑YES ❑ NO >599 OTHER D.CORROSION ❑ 1 POLYETHLENEWPAP 0 2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 RBERIREINFORCED PLU C PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE r&UNKNOWN ❑99 IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A(W 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(U)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 5ALUMINUM A U 6CONCRETE A U ] STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 06 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 O S 2 INVENTORY RECONCILIATION P 6 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USE.(MO/YR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? F-1 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# TANK ID# ® O O O O CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE RII'on>6 CrSf [� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT# BV: FORM B(B-29-98) THIS FORM MUST BE ACCOMPAN A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY