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STATE OF CALIFORN* WATER RESOURCES CONTROOARD FORM `B': JJNDERGROLIND STORAGE TANK PROGRAM ' P= TANK TANK PERMIT APPLICATION INFORMATION CO ETE A SEPARATE FORM WITH THE FOLLOWING I . MATION FOR EACH TANK. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT RANGE OF INFORMATION El7 PERMANENTLY CLOSED TANK ICT ONE ITEM F-12 INTERIM PERMIT F-14 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: oc 5 lemur/ OSA..- FARM TANK-VES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY co /� a) A. OWNERS TANK ID# E. MANUFACTURED BY'. I'L Ic .A C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS. IL 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 P TROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT 4 OIL ❑ 1 P DUCT ❑4 GASAHOL ❑ 5 J FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN 2 WASTE ❑ 7 MEFHANOL 9 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.a le c,it C.A.S.#: s III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑ 1 UBLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM LV GLE WALLED ❑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 ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F--] 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 P NOUC LINING LINING F-15 GLASS LINING ❑fi UNLINED 95 U OWN ❑ IS UNING MATERIAL COMPATIBLE WITH 1W%METHANOL? ❑YES [:] NO OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT n 3yW-WRAP ❑ 4 RBERGLASSREINFORCEDPLISTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE M95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A JU 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 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSISTEEL 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 AID 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 S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MCNITORING WELLS O P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 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. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FA/CILITY/,IID# TANK IDS)# CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY:C r4 - FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIED SY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A 7URRENT FORMA' HAS BEEN FILED 6 DATA PROCESSING COPY