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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM = � e 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 RMANENTLY CLOSE ONE ITEM F-] 2 INTERIM PERMIT F] 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: all &jU Uz4FARM TANK-YES D NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I� A. OWNERS TANK IDR '7-� B. MANUFACTURED BY: C. YEAR INSTALLED r J I D. TANK CAPACITY IN GALLONS: -COO II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. 1 , A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB C. ®'j UNLEADED ❑2 LEADED ❑3 DIESEL F-13 CHEMICAL PRODUCT F-14 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ M 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.R OAZ'64 C.A.S.#: .111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ I DOUBIE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 021 SINGLE WALLED ❑4 SECONDARY CONTAINMENT 0 9 OTHER STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B IOD%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL. ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 A DLINING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 10010 METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION F-1 I PoLyErHLENEWRAP2 PROTECTION [-]5 CATHODIC PROTECTION ❑91TNNE AR OR HALT ❑❑ 95V UNKNOWN ❑99INYL WRAP 4 OTHER ERLASS REINFORCED PLASTIC 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 99 OTHER B. CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 81 XM 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 I VISUAL CHECK P S 2 INVENTORY RECONCILIATION S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS rL✓I P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER I -VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED GATE LAST USED(MO/YR) 2. ESTIMATE QUANTITY OF 3. WAS TAN FILLED WITH SU EMAINING IN T IA ❑ ❑ NO GALLONS I L? YES THIS FORM AAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLE15GE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# i d I o 26 >--I IDO o CU�ENTLO�ALAGENC�CILITY ID 0 APPR /' AIJE PHONE 0 WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL ATE I VT,PERMIT EXPIRATION DATE CMECN# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: FORMB13-7-8e1 THIS FORM MUST BE ACCOMPANItnY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS." RRENT FORMA' HASBEENFILED DATA PROCESSING COPY