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STATE OF CALIFORI* WATER RESOURCES CONT BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM moo; TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT E:j 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION10 ONE ITEM 0 Z PERMANENTLY CLOSED TANK 2 INTERIM PERMIT Ej 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE L�J'b TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 09 5 + IV I mak T-I'1 CtCC-l;_ FARM TANK-YES NO 4bb I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY W A. OWNER STANK ID a B, MANUFACTURED BY R (� O YEAR INSTALLED ^�L D. TANK CAPACITY IN GALLONS: LA n� II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. F_� 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. U,I, C. ❑ 1 UNLEADED 2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT 4 OIL 5 HAZARDOUS [:j1 PRODUCT E] 4 �ASnqHpLA '� 5 JET FUEL El 6 AVIATION GAS 80 EMPTY �' -UNKNOWN 2 WASTE 7 A4E7HA OL .OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# � � CA S.a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN SOX A,B,C,S D A.TYPE OF ❑ I DOUBLE WALLED E]3 SINGLE WALLED WITH EXTERIOR LINER -Q-95-UNKNOWNSYSTEM 2 SINGLE WALLED Ej 4 SECONDARY CONTAINMENT Ej 99 OTHER B.TANK I STEEL/IRON E]2 STAINLESS STEEL 3 FIBERGLASS 0 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 1:1 6 POLYVINYLCHLORIDE 7 ALUMINUM 0 8 100%METHANOL COMPATIBLE FRP ED 9 BRONZE 0 10 GALVANIZED STEEL Q851"NOWN 0 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED 0 2 ALKYD LINING 3 EPDXY LINING 1-1 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING 1:1 6 UNLINED IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES NO W"- OTHER V 1'4 D. CORROSION ❑ I POLYS HLENE WRAP D 2 TAR OR ASPHALT 3 VINYL WRAP `Sf'❑W-- ""4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION D 91 NONE —E3-95-UNKNOWN N 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 B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 5 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U S ALUMINUM A U fi CONCRETE A U ] STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLEFRP A U 9 GALVANIZED STEEL A U 5 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. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELE MONITOR p 5 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S ] PRESSURE TESTING P S 91 NONE P 5 UNKNOWN P 5 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN 3. WAS TANK FILLED WITH '�-- 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 LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY ID N 0-T_ L-1 I APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER QC 2 11 - 2 ,% PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTN BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A'