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. . .. .1 t')X' 3, STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION - �% COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. Z 0 10 MARK ONLY ❑ I NEWPERMIT ❑ 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 O W FACILITY/SITE NAME WHERE TANK IS INSTALLED: '30.2- FARM TANK-YES❑ NO Cal I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY to to A. OWNERS TANK ID R B. MANUFACTURED BY: W C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: (f II. TANK qfONTENTS IF(A.1),IS MARKED,COMPLETE ITEM M IF(A.1),IS NOT MARKED,COMPLETE REM D. A. VI MOTOR VEHICLE FUEL ❑2 PETROLEUM B. / C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL U ' 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 A CAS.N CA.S.I: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALED ❑4 SECONDARYCONTNNLIENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑8 IM%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBERLINED 2 ALKYO UNING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ❑ BUMNGMATERIAL COMPATIBLE WITH 1M%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHIENE WRAP ❑2TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NDNE ❑95 UNKNOWN ❑99 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 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 STEELPRON 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 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. P S t VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS v 3 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 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 SUBSTANCE REMAINING IN GALLON/ INERT MATERIAL? E-]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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY f JURISDICTION R AGENCY M FACILITY ID M TANK ID N CURRENT LOCAL AGENCY FACILITY ID S APPROVED BY NAME PHONE B WITH AREA CODE LE'6�REFrd PERMIT NU R PERMITAPPROVAL GATE TiRNR EXPIMHNI TDAT[ CHECK R PERMIT AMOUNT SURCHARGE AMT. FEE COOS RECEIPT E BY: 1 . K0 ;B(E-29-88) TNIS FARM UST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA HAS BEEN FILED