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STATE OF CALIFORN WATER RESOURCES CONTR� ARD .a FORM `B': UNDERGROUND STORAGE TANK PROGRAM �o TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWINGjWdRMATION FOR EACH TANK. l� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS TAN ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE B TANK REMOVED G►� FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES NO N a) 1. TANK DESCRIPTION COMPLETE ALL ITEMS-If UNKNOWN-SO SPECIFY A. OWNERS TANK ID# C2 67B. MANUFACTURED BY: ce"o& C. YEAR INSTALLED [,Cp r[ D. TANK CAPACITY IN GALLONS: h II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT 4 OIL1 PRODUCT F-] 4 GASAHOL 5 JET FUEL ❑ 6 AVIATION GAS El5 HAZARDOUS E] 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&C.A.S.# C.A.S,to: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,8,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER E�f%UNKNOWN SYSTEM ❑ 2 SINGLE WALLED 4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE 07 INUM E]8 10096 METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEELV95NOWN 99 OTHER C. INTERIOR ElI RUBBER LINED 2 ALKYO LINING 3 EPDXY LINING MrUNKNOWN NOCK LINING LINING F-] 5 GLASS LINING ❑6 UNLINED ISUNINGMATERIAL COMPATIBLE WITH 100%METHANOL? YES [::] NO 99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP 2 TARORASPHALT M"95 3 LWRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION 91 NONE 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 95 UNKNOWN U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U 91 NONE A 95 UNKNOWN U 99 OTHER A U 1 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 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 95 UNK OWN 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 VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 NIC MONITOR P S 5 GROUND WATER MONITORING WELLS P $ 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 95 UNKNOWN P S 99 OTHER 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? ElYES ❑ 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# F I # TANK ID# 3 9 D4, 00 0 � CURR�LOALG�Y]FAC ITY ID# AP ROVED BY NAM/E� �g PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: i FORM B(6-29-68) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY