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STATE OF CALIFORNIO WATER RESOURCES CONTRCOARD FORM B': UNDE GROUND STORAGE TANK PRO AM ' TANK TANK PERMIT APPLICATION INFORMATION m �� COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - _- z P., 1 O 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 Er8 TANK REMOVED 09 FACILITY/SITE NAME WHERE TANK IS INSTALLED: LQ FARM TANK-YES❑ NO � .� W 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY a) A. OWNERS TANK ID# S I I B. MANUFACTURED BY: LLAk, C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: sm II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. �Z1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 0<2 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT ❑4 OIL Y9i 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 ❑ 1 DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER Q�95 UNKNOWN SYSTEM [:] 2 SINGUEWAUED E]4 SEDONOARY CONTAINMENT �❑99 OTHER STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3FIBERGLASS ❑4STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK fSel MATERIAL 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE F-] 7 ALUMINUM ❑ 8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR F--] 1 RUBBER LINED ❑2 AUXYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑5 GLASS LINING ❑6 UNLINED 95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH IOD%METHANOL? ❑YES ❑ NO 99 OTHER D. CORROSION ❑I POLYETHIENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 5?L95 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 ACE.') UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U 91 NONE A 9 NKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A //U++��6 CONC A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP LM/J A U 9 GALVANIZED STEEL A NKNOWN 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 5 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 S 6 PRECISION TESTING P S 7 PRESSURE TESTING S 9 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USE 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES [_-] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# [3E I aI ci] lolololil ,- CURRENTACAL AGENCY FACILITY ID k APPROVED BY NAME 6 E �' PHONE N WITH AREA CODE _ �xL _� Ccs 11 ' 1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKN PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPTN BY: FORM B(6-29-86) THIS FORM MUST BE ACCOMPANIE Y A FACILITY/SITE APPLICATION, FORM `A',UNLESS A H ENT FORMA' HAS BEEN FILED nATA ORnrFQQIMn rnDV