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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM =tea TANK TANK PERMIT APPLICATION INFORMATION � m COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - Z i0 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED m N I FACILITY/SITE NAME WHERE TANK IS INSTALLED: A,ks LAj FARM TANK-YES❑ NO ❑ .� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY N A. OWNERS TANK ID# V B. MANUFACTURED BY: j C. YEAR INSTALLED 1 5 1 D. TANK CAPACITY IN GALLONS. d II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITE D. A. gg4,MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑4 OIL � PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.# - C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,IL D A.TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER RrWUNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ i STEEL/IRDN ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL [[�IVNKNOWN ❑ 99 OTHER C. INTERIOR F7 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING [--15 GIASSUNING E]6 UNLINED 6j.%UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IDD%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYEiHLENE WRAP ❑2 TARORASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE g95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U 3 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 U 5 UNKNOWN A U 99 OTHER A U 1 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 A�U' 6�CONCRETE A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A05 UNKNOWN A U 99 OTHER i 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 CPS 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P B 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 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 GALLONS SUBSTANCE REMAINING IN INERT MATERIAL' ❑YES L] 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# p 0 1113 00- 1(7 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE lg1m ejkl= 2 C I/ g PERMITNUMSER PERMIT APPROVAL DATE PERMIT EXPIRAirION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-86) THIS FORM MUST BE ACCOMPANIEVWA FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CNTRENT FORMA HAS BEEN FILED DATA PROCESSING COPY