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STATE OF CALIFORN4 WATER RESOURCESCONTR(.30ARD FORM 'B': I N E GROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN FORMATION FOR EACH TANK. z• !O MARK ONLY NEW PERMIT ❑3 RENEWAL PERMIT EVCHANGE OF INFORMATION ❑ 7 PERMANENTLY C OS K ONE ITEM PQ INTERIM PERMIT F-14 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED d FACILITY/SITE NAME WHERE TANK IS INSTALLED: 9 L10 40 KS Q - FARM TANK-YES❑ NO 411, 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# 12, 8. MANUFACTURED BY: C YEAR INSTALLED D. TANK CAPACITY IN GALLONSd Q II. TANKjCONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. E0 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C ❑ 1 UNLEADED E] 2 LEADED 3 DIESEL F-13 CHEMICAL PRODUCT ❑d OILRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY [1] 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&C.A.S.# C.A.S:#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ DOLBLEWALLED ❑ 3 SINGLE WALLED WITH OnRIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER 10 1 STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 SIEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 188%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL D 95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ 1 RUBBER LINE ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 P NOUC LINING LINING F-15 GLASS UNING ❑6 UNUNED 5 UNKNOWN ` ❑ IS LINING MATERIAL COMPATIBLE WITH IOD%METHANOL? ❑YES ❑ NO �99 OTHER D.CORROSION ❑ 1 POLYEIHLENE WRAP ❑2 TAR OR ASPHALT ❑3 JOWLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONELid 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IFUNDERGROUND,BOTH IFAPPLICABLE A.SYSTEM TYPE A 0 1 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 A U 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 A U 91 NONE C.MATERIAL A U 5 ALUMINUM A }L 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A UU 95 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. O I P 8 1 VISUAL CHECK .P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS 8 6 PRECISIONTESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH GALLONS SUBSTANCE REMAINING IN 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 IDN TANK ID# 16101 1 I OOUZ CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAM PHONE N WITH AREA CODE fl U l'7 Gr/.� PERMIT NUMBER PERMIT APPROVAL DA PERMIT EXPIRATION DATE /Z v CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE -RECEIPT# BY PV FORM B(s-z9ae) THIS FORM MUST BE ACCOMPANIEDSY A FACILITY/SITE APPLICATION, FORM'A',UNLESS A CURRENT FORMA' HAS BEEN FILED J 1 =.(A PROCESSING COPY