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STATE E OF CALIFORNO WATER RESOURCES CONTI0BOARD =, FORM 'B': UNDE GROUND STORAGE TANK PROGRAM 1 TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I 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 yy FACILITY/SITE NAME WHERE TANK IS INSTALLED: let- KCAFeW4,49 Q( C 1vtIN0eAvE. FARM TANK-YES❑ NO �+ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY SrK - ea gsaoZ •a A. OWNERS TANK ID N N B. MANUFACTURED BY: W C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: SA,00,0 GA L !;Wee IJn�. •'3 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. a, �J[ A. [2'1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. I UNLEADEO ❑2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ < OIL ❑1 PRODUCT ❑ ( 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 6 C.A.S.N C.A.S.X: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,B D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑-26MGLE WALLED ❑ 1 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 RBERGLASS ❑/STEEL CIADW/FIBERGLASS REINFORCED FUSTIC B.TANK MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL E/ 95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑2 MOD LINING ❑ 3 EPDXYUNING ❑/PHENOLIC UNING LINING ❑5 GLASS LINING ❑6 UNUNED UNKNOWN ❑ ISLINING MATERIAL COMPATIBLEWITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑/FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 2-9-5 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND. U IFUNDERGROUND,BOTH IFAPPLICABLE A SYSTEM TYPE A U I SUCTION ArUh 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 9 NKNOWN A U 99 OTHER A LA I STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A' U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A O95 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 6 1 VISUAL CHECK P 6 2 INVENTORY RECONCILIATION P 6 3 VADOSE WELLS P 6 A ELECTRONIC MONITOR P B 5 GROUND WATEjiflf)NITORING WELLS P 8 6 PRECISION TESTING 6 7 PRESSURE TESTING P 6 91 NONE P 5 95 UNKNOWN P S 99 OTHER f//L VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF3.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. APPLICANTS NAME(PRINTED A SIGNATURE) DATE I LOCAL AGENCY USE ONLY COUNTY 6 JURISDICTION B AGENCY B FACILITY ID B TANK ID M L__l—J__.J = o o 1 ( g 3 1 n o CURRENT LOCAL AGENCY FACILITY ID 6 APPROVED BY NAME PHONE F WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK 6 PERMIT AMOUNT 81 CHARGE AMT. FEE CODE RPT E BY: FT FORMB(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FO R M 'A',UNLESS A CURRENT fORM'A' NAS BEEN FILED DATA PROCESSINr 1',OPv