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STATE OF CALIFORNU' WATER RESOURCES CONTRO' 'OARD FORM 'B': UNDERGROUND STORAGE TANK PROMAM 4 �' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INPRMATION FOR EACH TANK. - Z iC MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMITCHANGE OF INFORMATION ❑7 PERMANENTLY ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑e TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1 atA4 A (V 1- �J /eES o FARM TANK-YNO (j( �j , 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY /9 Kl A. OWNERS TANK ID# B. MANUFACTURED BY: VIC C. YEAR INSTALLED d I D. TANK CAPACITY IN GALLONS' OQ II. TANK CONTENTS IF(A.1),IS M RKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A_ ❑ 1 MOTOR VEHICLE FUEL 2 ROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT 4 OIL RODUCT ❑4 GASAHOL ❑ 5 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.# 6 �r/ C.A.S.M III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑ 1 DOUBLEWALLEO ❑3 SINGLE WALLED WITH EXTERIOR LINER E�fS5 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLAS5 Li'I ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC F] NCRETE E]B.TANK 5 CO6 POLYVINYL CHLORIDE 7 AL UM MATERIAL ❑8100%METHANOL COMPATIBLE FAP ❑9 BRONZE ❑ 10 GALVANIZED STEEL 5 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYDUNING E-] ❑3 EPDXY UNING 4 ENOUC UNING LINING ❑ 5 CUSS UNING ❑6 UNLINED 95 U N ❑IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL2 ❑YES ❑ NO OTHER D. CORROSION ❑ 1 PoLYETHLENEWMP ❑2 TAR OR ASPHALT ❑3 VI P ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE EL44UNKNON ❑ 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 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLEWALLED A U 2 DOUBLEWALLED A U 3 LINED TRENCH A U 91 NONE A U 5 UNKNOWN A U 99 OTHER A U 1 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 5ALUMINUM A CONCRETE A U 7STEEL CLAD WEEP A U 810M METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U UNKNOWN A U 99 OTHER V. AK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 6 P 5 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS *fpp 6 PRECISION TESTING P S 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 QUANTITY OF3.WAS TANK FILLED WITH GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? E]YES U] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID M TANK ID# CURRENT LOCAL AGENCY FAITY IDN APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKN PERMIT AMOUNTI SURCHARGE AMT. I FEE CODE RECEIPT# BY: FORM B E 29-55; THIS FORM MUST BE ACCOMPANIEWI'A FACILITY/SITE APPLICATION, FORM 'A',UNLESS AVARENT FORM'K HAS BEEN FILED DATA PROCESSING COPY