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STATE OF CALIFORPR 4 WATER RESOURCES CONT L BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM ` TANK TANK PERMIT APPLICATION INFORMATION m COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY [j-eKEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CV"K ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED/o/ N FACILITY/SITE NAME WHERE TANK IS INSTALLED: rwS. FARMTANK-YES❑ NO (jl I. TANKDESCRIPTION COMPLETE ALL ITEMS-IFUNKNO"-SO IFY W A. OWNERS TANK ID# �5 Z B. MANUFACTURED BY: N C. YEAR INSTALLED11 yy D. TANK CAPACITY IN GALLONS: /D Q II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. FfTl MOTOR VEHICLE FUEL ❑ 2 PETROLEUM G_ C. ❑ 1 UNLEADED ❑ 2 LEADED DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL fJ ' PRODUCT ❑4 GASAHOL ❑ 5 JET 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 f HAZARDOUS SUBSTANCE STORED&C.A.S.# A11A III. TANK CONSTRUCTION MARK ONE ITEM NLY IN BOX A,13,C,&D A.TYPE OF ❑I WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECDNDARP CONTAINMENT ❑99 OTHER I 1 STERUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGUSS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8180%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑98'UNKNOWN ❑99 OTHER ' C.INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING F-13 EPDXY UNING ❑ 4 PHENOLIC UNING LINING ❑5 GLASS UNING �6 UNLINED ❑95 UNKNOWN ❑ ISLINING MATERIAL COMPATIBLE NTH 100%METHANOL? ❑YES ❑ NO � OTHER D.CORROSION ❑ I POLYERRENE WRAP Efr2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER S.CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE i C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U S 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A L995 UNKNOWN A U 99 OTHER Y LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK 8 2 INVENTORY RECONCILIATION P 8 3.VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS / P 6 PRECISION TESTING(f 8 7 PRESSURE TESTING P 8 0 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE USED(MO/YR) 2. ESTI MAT QUANTITY OF 3.W TANK FILLED WITH SUBST CE REMAINING IN MATERIAL? DYES ❑NO GALLONS JAM 04 4 THIS FORM t4AS BEEN COMPLETED UNDER PENALTY F PERJURY,AND TO THE BEST OF MY KN WLEDGE,IS TRUE AND CORRECT. IAPPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# L9 i � I Ie) la 10 C( b/A�SIN �CFACILITY IDN APPROVED BY t r7-1 PHONE N WITH AREA CODE PFAMIT NUMBER PER 1� DATE VE/(/_ r'(AP'ERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHAO/RGE AMT. JSP FEE CODE RECEIPT# BY: FORM B(6-29-68) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'AI,UNLESS ATORRENT FORMA' HAS BEEN FILED