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STATE OF CALIFORNIA WATER RESOURCES CONTROI ')ARD FORM 'B': UNDEFMROUND STORAGE TANK PROGRAM (az TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 2r-5 CHANGE OF INFORMATION ❑7 PERMANENTLY C ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑16 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED / JJJJ N FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARMTANK-YE$❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY ~ I-� A. OWNERS TANK ID P '-j, B. MANUFACTURED BY: C. YEARINSTALLED D. TANK CAPACITY IN GALLONS: 4-oU D II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. I MOTOR CLE A Z3 CHEMICAL PIRODUCTL ❑ 4 OA PETROLEUM B i PRODUCT C ❑<GASAHO UNLEADED ❑ 5 JET FUEL 6 AVIATION GAS ED LY3 DIESEL ❑ ❑ ❑ ❑ ❑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 HAZARDOUS SUBSTANCE STORED&C.A.S.B C.A.S.R: 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 0 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER [ 1 STEEURON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 188%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING Ef6 UNUNED ©95 UNKNOWNS ❑ IS UNING MATERAL COMPATIBLE WITH IN%METHANOL? ❑YES ❑ NO [2199 OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3 WYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMA N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION 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 AU 1 STEELARON A U 2 STAINLESSSTEEL 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 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U W OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. / P S 1 VISUAL CHECK P 3 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P PRECISION TESTING S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMAT D DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH SUBSTAN REMAINING IN INERT M L? ❑YES ❑NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY O PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY p JURISDICTION P AGENCY P FACILITY 10 M TANK ID N 3 I old CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DA E%PIRATION DATE CRECKM PERMITAMOUNT SURCHARGE AMTFEE RECEIPT BY: 1 _ FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIAFACILITY/SITE APPLICATION, FORM 'A',UNLESS At= FORMA` HAS BEEN FILED DATA PROCESSING COPY