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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 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 NEWPERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIMPERMIT ❑4 AMENDEOPERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED C FACILITY/SITE NAME WHERE TANK 181NSTALLED: FARMTANK-YES❑ NO U z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY +� A. OWNERSTANK ID p �' B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 5150 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 R. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF bwct HAZARDOUS SUBSTANCE STORED&C.A.S.# G.A4. B-t XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM Eq'I9NGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER SfEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B IDA METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER UNED ❑ 2 ALKYD LINING F-13 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING 5�4UNUNED ❑ 95 UNKNOWN ❑ISUNING MATERMLCDMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TARORASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ©^JTNONE ❑95 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 X 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A(Ul 95 UNKNOWN A U 99 OTHER A 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLEFRP A U 9 GALVANIZEDSTEEL 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. M A P S I VISUAL CHECK o S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 6 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER # VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK 61LLED WITH GALLONS I SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT, j APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# o 10a 3 o (; 10, 1 I CURRENT LOCAL AGE�NCY FACILITY IDN APP OVED BY N E �� PHONE#WITH AREA CODE T PERMIT NUMBER PERMITAPPROVAL DATE ERMIT 7PIRATION DATE CHECK# PERMIT AMOUNT I SURCHARGE AMT. FEE CODE RECEIPT N BY: FORM 8(3-7-88) THIS FORM MUST BE ACCOMPANIOW FACILITY/SITE APPLICATION, FORM `A',UNLESS A CM0ENT FORM'A' HAS BEEN FILED