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STATE OF CALIFORNItS PRO AWATER RESOURCES CONTROjrARD FORM B': UNDE ROUND STORAGE TANK M TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. -_ro z 10 MARK ONLY ❑ 1NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑7 TANK REMOVED C9 IV FACILITY/SITE NAME WHERE TANK IS INSTALLED: M Ckn Lt j�,FARM TANK-YES❑ NO E;4- j►, YAJ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY ap A. OWNERS TANK ID# /-I L I B. MANUFACTURED BY: nl<- N C. YEAR INSTALLED I I tiif-- I D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C, ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL � ❑ 3 CHEMICAL PRODUCT <OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN �2 WASTE ❑ 7 METHANOL ©'99 OTHER D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF -" n - " HAZARDOUS SUBSTANCE STORED&C.A.S.# O'D _ I� C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,S D A TYPE OF ❑ I OOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM [3-111,113LE WAILED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 IDG%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL EJ96T1NKNOWN ❑99 OTHER ❑ 1 RUBBER UNED ❑ 2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOUC UNING C.INTERIOR N RI R F-15 GLASS LINING ❑6 UNLINED NKNOWNNG p v 1 yl ��A ,��c """��/ (. E:] IS LINING MATERIAL COMPATIBLE WITH 1D0%METHANOL? ❑YES ❑ NO 99 OTHER `�k D. CORROSION ❑ 1 POLYEfHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑-MTNKNOWN ❑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 A 9 UNKNOWN p 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 ig 9 NKNOWN A U 99 OTHER A U i STEEL/IRON 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 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A QI 9 OWN 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 S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE a S 9 NKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF &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# ® Dv 19 15 1 a 14 1 10 1 0 0 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME �� PHONE WITH AREA CODE Lf ( PERMIT NUMBER PERMIT APPROVAL DATE CC�PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGEAMT. FEECODE RECEIPT# BY: 16 FORM 8(6-29-88) THIS FORM MUST BE ACCOMP IED BY A FACILRY/S TE APPLICATION, FORM'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY