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STATE OF CALIFORNF WATER RESOURCES CONTR BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION m COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK- -_- z 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL/%ED TANK ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED V ca FACILITY/SITE NAME WHERE TANK IS INSTALLED: / f(QO �✓+ _ FARMTANK-YESEn NO ❑ N' I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY C� A. OWNERSTANKID# dl B. MANUFACTURED BY: / "'• C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: .SSD 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 B. C. ❑ 1 UNLEADED2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL I PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ T METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAMEOF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: AJA III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM dSINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESSSTEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 MINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER UNEO ❑2 ALKYD LINING ❑3 EPDXYLINING ❑4 PHENOLIC LINING LINING NUNED WN LINING GLASS INN[-] S UNG MATERIAL COMPATIBLE❑WITH I1Do%METHANOL? ❑YES [:] NO ER OTHL4vt- D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TARORASPHALT ❑3VIWL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODICPROTECTION ❑91 NONE fii'UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IFUNDERGROUND,BOTH IFAPPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A t95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE U)95 UNKNOWN A U 99 OTHER A U I STEELPRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FISERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A(�P5 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. N e Nf P 8 6 VISUAL PRECISIONTESTINGP 8 7 PRESSURE RE RECONCILIATION ESTING P 8 331VNDOEE WELLS P 8 95 UNKNOWN OWN MONITOR P a s GRO99 UND WATER MONITORING WELLS VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS 3ANK FILLED WITH x /PA A SUBSTANC JAINING IN GALLONS E TERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF kRJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3 1 1 Jo lo CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE ,&7-r0 '7 7 r PERMIT NUMBER PERMIT APPROVAL DATE PERMIT E PIRA ION DATE fHFCK# PERYR AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: 1 conn+©re-29-38I THIS FORM MUST BE ACCOMPANIEOBY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY