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STATE OF CALIFORNIS WATER RESOURCES CONTROOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY NEW PERMIT ❑3 RENEWALPERMI7 ,.. 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYC[:OSEDTANI4 ONE ITEM �'3 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3 Q / QYLJ FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 10 A. OWNERS TANK IDR !N B. MANUFACTURED BY: K C- YEAR INSTALLED L770 D. TANK CAPACITY IN GALLONS: 1-150 11. TANK 9ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. W A. 1 MOTOR VEHICLE FUEL ❑ 2 ❑3 CHEMIGALPRODUCT PETROLEUM B. G N ❑ 4 OIL ❑ 1 UNLEADED ❑2 LEADED DIESEL Df PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE F-17 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.B.A C.A.S.k: XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WRH IXTEROR LINER ❑95 UNKNOWN SYSTEM ✓f2 SINGLEWALLED ❑4 SECONDARYOONTAINMENT ❑99 OTHER B.TANK 1 STEEUIRON ED2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC ❑5 CONCRETE MATERIAL ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑6100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED MEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ 1 RIBBER UNED ❑p ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑5 GLASS LINING ❑6 UNUNED ©95 UNKNOWN ❑ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑9g OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE u"UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A WABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A O2WSUCTION 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 LINEDTRENCH A 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 C. MATERIAL A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A(D95 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 3 1 VISUAL CHECK O S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS PO 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE- P S 95 UNKNOWN P S 99 OTHER 9 VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF pJy SUBSTANCE REMAINING IN 3. WAS TANK FILLED WITH GALLONS INERT MATERIAL? ❑y6g ❑ 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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY k JURISDICTION k AGENCY k FACILITY ID k OOKIp / CURRENT LOCAL AGENCY FACILITY ID M OVEQ BY NAME IPHONE M WITH AREA CODE PERMITNUMBER �/L PERMITAPPROVALOATE PERMIT EXPIRATION DATE 00/ / (� al �� /a 31 8I? CHECKk PERMIT AMOUNT SURCHARGE AMT. I FEE CODE RE EP / BY: FORMBS&7-88) THIS FORM MUST BE ACCOMPAN ., YA FACILITY/SITE APPLICATION, FORM 'A',UNLESS MIRRIENT FORMA' HAS BEEN FILED �L a 1 DATA PROCESS Opy