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STATE OF CALIFORNI* WATER RESOURCES CONTRO�ARD FORM 'B': UNDE ROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 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 �ANK REMOVED O FACILITY/SITE NAME WHERE TANK IS INSTALLED: N 5. n d QCC.,. FARMTANK-YES❑ NO .p. I. TANKDESCRIPTION COMPLETE ALL ITEMI IF UNKNOWN—SO SPECIFY � Fj A. OWNERS TANK ID# B. MANUFACTURED BY: tl. CO C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 73 SID II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1MOTOR VEHICLE FUEL F__] 2 PETROLEUM B. C. ❑ 1 UNLEADED LJ 2 LEADED E] 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL Xi 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&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL F-] ❑ ALUMINUM ❑5 CONCRETE 6 POLYVINYLCHLORIDE 7 8100%METHANOL COMPATIBLE FRP ❑ ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ ❑ ❑I RUBBER LINED ❑2 ALKYD LINING yo 3 EPDXY LINING 4 PHENOLIC LINING � � LINING ❑ 5 GLASS LINING 17� UNLINED ❑ 95 UNKNOWN 17, ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP TAR OR ASPHALT ❑ 3VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A 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 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 25TAINLE55 STEELA U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUMCONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U 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 3 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 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? [:]YES ❑ 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# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3 Q� a ( 4 11 CURRENT LOCAL AGENCY FAGILI h ,w ppppOV NA PHONE N WITH AREA CODE IIIV 1` IY I ♦ �' PERMIT NUMB ER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ��11 CHECK p PERMIT AMOUNT SURCHARGE AMT. FEE CODE CEIPT N BY: -- FORM a(s-z9-ee) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROC;SING COPY