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STATE OF CALIFORNh WATER RESOURCESCONTR�- OARD " •'•'':� FORM 'B': UNDERGROUND STORAGE TANK PROGRAM ,A TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. o Z IO MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATIONERMANENTLYLOSED TA CK ONE ITEM El INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVE FACILITY/SITE NAME WHERE TANK IS INSTALLED: Q /L}'YVIU ,S /✓ fARM WK-YESEJ NO DrO I. TANK DESCRIPTION COMPLETE ALL ITEMS IF UNKNOWN-SO SPECIFY A A. OWNERS TANK IDN B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: �0 0 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A O 3 COTORVEHICLEHEMICAL FUEL ❑2 PETROLEUM B 1 PRODUCT C ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 4 GASAHOL ❑5 FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL EfJ99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF n� Y n,-e I HAZARDOUS SUBSTANCE STORED 8 C.A.S.N Y (�Gi" Lam'( / C.A.S.N: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑ 1 Q96BLE WALLED ❑ 3 SNGLE WALLED WITH D(TERIOR LINER 5 UNKNOWN SYSTEM SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEELPRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE n 7 WNUM ❑B 10D%METHANOL COMPATIBLE FRP MATERIAL FU'r ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑3 EPDXYLINING F7 4 L�T/' UC LINING LINING ❑5 GLASS LINING ❑ 6 UNLINED 5 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLEWITH ID0%METHANOL? ❑YES ❑ NO F�W OTHER D. CORROSION ❑ I POLVErHLENEWRAP ❑2 TAR OR ASPHALT 3 VINY AP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑9I NONE 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 9/ 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 A W95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U S ALUMINUM ;g CONCRETE A U 7 STEEL CLAD W/FRP A U B 10096 METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL5 UNKNOWN A U 99 OTHER V. EAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS Lv P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P(SAS UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. 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 R JURISDICTION B AGENCY B FACILITY ID R TANK ID M 0 1 ItOo 1 o CURRENT LOCAL AGENCY FACILITY/ ID F O ro APPROVED BY NAME PHONE 4 WITH AREA CODE PERMIT NUMBER M PERMIT APPROVAL DATE PERMIT E%PIRATION DATE _lam CHECK 4 PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT F BY: , FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED