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STATE OF C,ALIFORN, WATER RESOURCES CONTR( IOARD FORM 'B': UNDERGROUND STORAGE TANK PROuRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z 40 MARK ONLY ❑ 1 NEW PERMIT F-1 3 RENEWAL PERMIT N-5-E1HANGE OF INFORMATION Ej 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT 714 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE [:]8 TANK REMOVED ,;)-, w FACILITY/SITE NAME WHERETANK ISINSTALLED: - ! FARM TANK-YESO NO OG I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY -4 A. OWNERS TANK IDM 3 B. MANUFACTURED BY: Ur ~ C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 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 F_�2 PETROLEUM B. C. 1 UNLEADED L]2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT 4 OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL 6 AVIATION GAS 5 HAZARDOUS 80 EMPTY 00 95 UNKNOWN Ej 2 WASTE Ej 7 METHANOL L]99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.W III. TANK CONSTRUCTION MARK ONE ITEM ONLYIN BOXA,B,C,BD I A. TYPE OF ❑ 1 DOUREWALLE 3 SINGLE WALLED WITH EXTERIOR LINER E:]95 UNKNOWN SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON 2 STAINLESS STEEL F_�3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B. TANK S["CONCRETE 6 POLYVINYLCHLORIDE F-] 7 ALUMINUM F-181 W%METHANOL COMPATIBLE FRP MATERIAL L✓� 9 BRONZE rrryyy�111 10 GALVANIZED STEEL E]95 UNKNOWN 99 OTHER 1 RUBBER LINED 2 ALKLDUNING 3 EPDXY UNING F-14 PHENOLIC LINING C. INTERIOR LINING 5 GLASS UNING 6 UNLINED [:] 95 UNKNOWN ISUNING MATERIAL COMPATIBLE WITH 1W%METHANOL? YES [:] NO 99 OTHER I �� D. CORROSION ❑ 1 POLYETHUNE WRAP TAR OR ASPHALT ❑3VINYLWRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE ❑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 PflESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTIONA 1 SINGLE WAI I E0 A 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 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 A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 6 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 IVISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P 6 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P PRECISIONTESTING S 7 PRESSURETESTING 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 FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E]YES E NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF AMY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY* FACILITY ID# TANK ID# mo CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL GATE PERMIT EXPIRATION DATE CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: �- FORM B(5-29-88) THIS FORM MUST BE ACCOMPAITED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLE. URRENT FORMA HAS BEEN FILED DATA PROCESSING COPY