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STATE OF CALIFORNI1b WATER RESOURCES CONTRC&OARD FORM `B': UNDE GROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ONE ITEM ❑ ❑5 CHANGE OF INFORMATION ❑7 P RMANENTLY CLOSED TA (� ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED Oq FACILITY/SITE NAME WHERE TANK III INSTALLED: 71 FARMTANK-YES❑ NO N I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID If / B. MANUFACTURED BY: 00 C. YEAR INSTALLED cn D. TANK CAPACITY IN GALLONS: �00II. TANK CO TENTS e7a ,9 IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL Flt'IrRODUCT ❑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 HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.p: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF ❑1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM INGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER EUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK5 CONCRETE MATERIA ❑ ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑10 GALVANIZED MEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ I RUBBERUNED ❑2 A LINING 3 EPDXYUNING ❑4 PHENOUGUNING LINING ❑5 GLASS LINING UNLINED ❑95 UNKNOWN ❑19 LINING MATERIAL COMPAT78LE WITH 100%MEIHANOLP ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP [] ❑2 TARORASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC ❑5 CATHODIC PROTECTION NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND=U 'BOTH IF APPLICABLE EE7! 1 SUCTIONSURE A U 3 GRAVITY A U 91 NONE U UNKNOWN A U 99 OTHER 1 SINGLE WABLE WALLED A U 3 LINED TRENCH A U 91 NONE1 STEEL/IROLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE S ALUMINUMCRETE A U ]STEEL CLAD W/FRP GALVANIZENOWN A U 6100%METHANOL COMPATIBLE FRP A U 99 07HER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. ' UAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 YAQO.SE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 1 W P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING 8 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTL CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/VR) 2. ES7IMATEO QUANTITY OF SUBSTANCE REMAINING IN 3.WAS TANK FILLED WITH GALLONS INERT MATERIAL? [DYES []NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FA^CIILLITY IIIDD'# OCJf TANK ID# CURRENT L09AL AGENCY FACILITY IID[# O 4 APPROVED Y^A Qyy PHONER WITH AREA CODE S PERMIT NUMBER PERMIT APPROVAL DATEPERM EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-e6) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY