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STATE OF CALIFOR ft WATER RES ACES CONT BOARD FORM 'B': UNDERGROUND STOP aE TANK PR GRAM TANK TANK PERMIT APPLY. TION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Epr5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO K ONE ITEM F-] 2 INTERIM PERMIT F--] 4 AMENDED PERMIT E]6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE FACILITY/SITE NAME WHERE TANK IS INSTALLED: o&k), FARM TANK-YBOU NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# tj 4- B. MANUFACTURED BY: l ' C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: O (JOv ( �� W II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. f p A. ❑ 1 MOTOR VEHICLE FUEL L.e ` PETROLEUM B. C. ❑ 1 UNLEADED ❑� 22 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 4 GASAHOL LSI 1:16 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 8 C.A.S.a A C.A.S.#: oil I LA Kill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.8 D A TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM r 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL M3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8160%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ 1 BER UNED ❑2 ALKYDUNING ❑3 EPDXYLINING ❑ 4 PHENOLICUNING C.LININ INTERIOR 5 GLASS LINING ❑6 UNLINED ❑ 95 UNKNOWN LINING ❑ ISUNING MATERIAL COMPATIBLEWITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 F18ERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION 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 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH 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 FIBERGLASS PIPE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 5 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 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS CISION PRES P S PRETESTING P S 7 SURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATE DATE LAST USED(MO/YR) 2. ESTIMA ED QUANTITY OF 3, WAS T K FILLED WITH A/ BU S fJ�E REMAINING IN R ERIAL? ❑yE$ ❑ NO ✓V GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY F 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# �,J � TANK ID# EE = = Do /11 3 6o c� 3 CURREf1):LOCALA AGENCY FACILITY IDp APP/iPVE B FME� jj�jj PHONE#WITH AREA CODE PERMITNUMBER E ZU PERMIT APPROVAL DATE PERMIT EXPIRATI NDA E ICHECKN PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: I -Loh FORM B(3-7-68) THIS FORM MUST BE ACCU----E A FACILITY/SITE APPLICATION, FORM'A',UNLE RENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY