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STATE OF CALIFORNIA _ WATER RESOURCES CONTROL P RD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM , TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - Z 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TA ONE ITEM ❑ 2INTERIM PERMIT El4 AMENDED PERMIT [:] 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 5 '� ^ w FACILITY/SITE NAME WHERE TANK IS INSTALLED: a S kgCQ FARM TANK-YES NO ❑ N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY O C71 A. OWNERS TANK IO A B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 1414 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOjMARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL F-13 CHEMICAL PRODUCT ❑ 4 OIL 1 RODUCT ❑ 4 GASAHOL -]5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY 5 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.M III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,6 D A.TYPE OF ❑1 DOUBLEWALLB) ❑ 3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT 99 OTHER F-11 STEOUIRON ❑ 2 STAINLESS STEEL ❑3 FIBERS IA ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ MATERIAL5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 UM ❑8100%METHANOLCDMPATIBLEFRP i ❑9 BRONZE ❑ 10 GALVANIZED STEEL95 UNKNOWN ❑%OTHER ❑ 1 RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXY LINING ❑4 PH UNING C.INTERIOR LINING ❑5 GLASSUNING ❑6 UNLINED UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHA14DL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 V AP ❑ 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 U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGL E A U 91 NONE C. MATERIAL A U 5 ALUMINUM AA U 7 STEELCLADW/FRP A U 6100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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 I VISUAL CHECK P 8 2 INVENTORY RECONGLIATION P 3 3 VADOSE WELLS P 8 NITOR P 8 5 GfiOUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P 95 UNKN0 P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE i 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONSINERT MATERIAL? ❑YES E]NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION 8 AGENCY R FACILITY ID B TANK ID B CURRENT LL AO�G`/FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER 'Ynl PERMIT APPROVAL DATE PERMIT EXPIRATION DATE [ , I CHECK N IP PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECENT R BY: W FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY