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STATE OF CALIFORNIA WATER RESOURCES CONTROL I %RD FORM B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION §° COMPLETE A SEPARATE FORM WITH THE FOLLOWING! RMATION FOR EACH TANK. Z 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS / ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE/S w FACILITY/SITE NAME WHERE TANK IS INSTALLED: sQ� ///EAG FARM TANK-YESE-14Orl N 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY red Z ZO A. OWNERS TANK IDM B. MANUFACTURED BY: C. YEAR INSTALLED G( 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 ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.M C.A.S.M: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,A D A. TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER NOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE 7AINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑10 GALVANIZED STEEL LY4 UNKNOWN ❑ 99 OTHER ❑ C. INTERIOR 1 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY UNING 4 PH LIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER O CORROSION F-1 1 PROTECTION E]5 CALTHODIC PROTECTION E]91TAR OR NONE HALT 3 VUNKNO'WN ❑M OTHER HHEERLASS REINFORCED FUSTIC IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 5 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A tygS 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 C. MATERIAL A U 5 ALUMINUM AU CONCRETE A U 7 STEELCLAOW/FAP A U 8108%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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. PS I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MONS) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ElNO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION M AGENCY M FACILITY ID M TANK ID M 0 CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE k WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE V1' CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N V l,✓ � FORM a I6-29-39I THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY