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STATE OF CALIFORNI. WATER RESOURCES CONTRC `OARD FORM 'B': UNDERGROUND 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 C K ONE ITEM F-12 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED/a/ FACILITY/SITE NAME WHERE TANK IS INSTALLED: V T FARM TANK-YES❑ NO:L4z I I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY O A. OWNERS TANK ID N O Z B. MANUFACTURED BY: { , C. YEAR INSTALLED -7 D. TANK CAPACITY IN GALLONS' w II. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A-1),IS NOT MARKED,COMPLETE ITEM D. (D A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 ROLEUM e. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT 4 OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑ 5 J FUEL ❑6 AVIATION GAS 1 ❑5 HAZARDOUS ❑BO EMPTY ❑ 95 UNKNOWN Z41-WASTE ❑7 METHANOL 9 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAMEOF �7 HAZARDOUS SUBSTANCE STORED&C.A.S.N C.A.S.W All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C.A D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH DDERIOR LINER ❑ 95 UNKNOWN SYSTEM Fel'SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER R-I'STEBUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 ODNCAE7E ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 18 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER LINED E]2 ALKYD LINING F-13 EPDXY LINING ❑d PHENOLICUNING LINING ❑5 GLASS UNINr,/G 6 UNUNED ❑M UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYEIHLENEWRAP [ET2TM OR ASPHALT ❑3WNYLWRAP ❑d FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IFUNDE OU NO,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U GRAVITY A U 99 OTHER B. CONSTRUCTION U SINGLE WALLED A U 2 DOUBLE WALLED A 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A(!)!5 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 VISUAL CHECK P 2 INVENTORY RECONGLIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P RECISION TESTIN 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 QUIPTITV OF3.W T NK FILLED WITH SUBST E ING IN T ATERIAL? ❑YES ❑ NO GALLONS THIS FORh HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF A4Y KNO LEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID# (' d 1 b L CURRENT LOCAL AGENCY FACILITY ID# APPROVED B N PHONE#WITH AREA CODE PERMIT NUMBER PERMIT 0 AL PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE A T. FEE CODE RECEIPT# BY: FORM B(3.7.8B) THIS FORM MUST BE ACCOMPANIEDMY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORMA' HAS BEEN FILED w a. kHuvca�,iY:: COPY —