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STATE OF CALIFORNIA WATER RESOURCES CONTROL ' ARD "`• ' FORM 'B': UNDEPROUND STORAGE TANK PROG AM TANK PERMIT APPLICATION INFORMATION ta " TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING')INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS ANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE El TANK REMOVED CLO FACILITY/SITE NAME WHERE TANK IS INSTALLED: j Y1,;-L- v K.III N _ FARM TANK-YES❑ NOLIZO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY yY ? A. OWNERS TANK ION B. MANUFACTURED BY: W C.YEAR INSTALLED ( c F-7 0. TANK CAPACITY IN GALLONS: 'G) d II. TANK CONTENTS IF(A-1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. CJS A. ❑ 1 MOTOR VEHICLE FUEL ❑ ETROIEUM V7C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT L SOIL ❑ 4 GASAHOL ❑ 5 J EL ❑ 6 AVIATIONGAS ❑ 5 HAZARDOUS ❑ BO EMPTY ❑ 95 UNKNOWN ❑ 7 METHANOL Ca�9'9 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C , HAZARDOUS SUBSTANCE STORED&C.A.S.N C.A.S.q: III. TANK CONSTR TION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENTIOR UN ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL M 3 FIBERGLASS ❑4 MEL CLAD W/FIBERGLASS REINFORCED PLASTIC S.TANK F7 CONCRETE ❑6 POLYVINYLCHLORIDE f77 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING 4 ENOUCUNING C.INTERIOR �jj LINING F-15 GLASS LINING F-] 6 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 HER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT F73 VINYLWRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UND ROUND,BOTH IF APPLICABLE .L SYSTEM TYPE A U I SUCTION A A 2 PRESSURE A 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 4 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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. ( S 1 VISUALCHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS S ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P 8 91 NONE P 3 95 UNKNOWN P 3 99 OTHER U 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 E] 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 1 LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N CURRENT LOCAL AGENCY FACILITYIp/�N�N��//,� J APPROVED BY NAME PHONE N WITH AREA CODE / " \(�' I ) PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE HECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT F BY: r1 FOHM B(6-2966) THIS FORM MUST BE ACCOMPAI.IE'BY A FACILITY/SITE AlPLICATION, FORM 'A',UNLES .. 'ARENT FORMA' HAS BEEN FILED DATA PROCESSING COPY