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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM w TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ - Z 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ANK REMOVED v9 FACILITY/SITE NAME WHERE TANK IS INSTALLED: �L FARM TANK-YES❑ NO `ISI .A CD I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY to A. OWNERS TANK ID# 01 I B. MANUFACTURED BY: LA Kf� C YEAR INSTALLED A 1A D. TANK CAPACITY IN GALLONS: 11. 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 BC ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL. F-] 4 [-]3 CHEMICAL PRODUCT E;j 1 PRODUCT ❑4 GASOHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN �R-V4ASFE ❑7 METHANOLOTHER(DESCRIBE IN ITEM D,BEL( ) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF � ^ HAZARROUS SUBSTANCE STORED&C.A.S.# �l�l�4 ( I C.A.S.C III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,i D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH D%IERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WAILED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ I SKEUIRON ❑2 STAINLESS STEEL ❑3FIBERGIASS ❑ 4MEL CLAD W/RBERGUISS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑ MATERIAL 6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%MEMMOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL Ffj 95 UNKNOWN ❑99 OTHER F-11 RUBBER LINED ❑2 ALKYDUNING F-]3 EPDXY UNING [:] 4 PHENOLICUNING C. ININGIOR ❑5 GLASS UNING ❑6 UNLINED UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? [-]YES ❑ NO ER D. CORROSION ❑ I POLYETHLB4E WRAP ❑2 TAR DR ASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE WN ❑ 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 US3 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U i SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNED TRENCH A U 91 NONE U_9 UNKNOWN A U 99 OTHER A U i STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM CONCRETE A U 7 STEELCLADW/FRP A U S 1DO%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U NKNOWN 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 S 3 VADOSE WELLLa JLv.S7 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 5 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE L _P-'S 95 UNKNOWN P B 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# m = = I Uc) b0 1 n CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK PERMIT AMOUNT SURCHARGEAMT. FEE CODE ` EIPT# BY: FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CIAREN�M'A' HAS B--------- DATA ENFILEDDATA PROCESSING COPY