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STATE OF CALIFORNIA WATER RESOURCES CONTRO�(F"ZARD FORM 'B': UNDERC;,ROUND STORAGE TANK PRO ,SAM ' TANK TANK PERMIT APPLICATION INFORMATION m COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ET;CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIMPERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 0 TANK REMOVED l FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARMTANK-YES❑ NO N � I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY -4 N A. OWNERS TANK ID# B. MANUFACTURED BY: U.K, (Q C. YEAR INSTALLED (,%. K D. TANK CAPACITY IN GALLONS: 5�QUO II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A7),IS NOT MARKED,COMPLETE ITEM D. A. Er1 MOTOR VEHICLE FUEL ❑2 PETROLEUMB. C. ❑ I UNLEADED 2 LEADED E]3 DIESEL F-13 CHEMICAL PRODUCT ❑4 OIL ❑1 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 HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.W III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE WALL® ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL F] STE � 9 BRONZE ❑ 10 GALVANIZED EL u 95 UNKNOWN ❑W OTHER ❑ I RUBBER LINED ❑2 AUClD LINING ❑3 EPDXY LINING ❑/ ENOLIC LINING C.INTERIOR LINING ❑ 5 GLASS LINING ❑6 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 10D%MEDNNOL9 ❑YES ❑ NO ❑99 OTHER D.CDRROBION ❑ i POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 NYLWRAP [:j4 RBERGLASS REINFORCED PLASOC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE LIJ 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 --#, U 95 UNKNOWN A U 99 OTHER B.CONBTRUCTIDN A U 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 FIBERGLASS PIPE A U 91 NONE Q MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P B 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE UST USED IMO/YR) 2. ESTIMATED QUANTITY OF 3.WAS FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO 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# JURISDICTION# AGENCY# FACILITY ID# TANK IDM 3o40 r 55 oC) r o CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE ,�.•Lf��?.�Tl PERMMNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKM PERMITAMOUNT PURCHARGE AMT. FEE CODE RECEIPT# BY: -i �� FORM B(6-29-88) THIS FORM MUST BE ACCOMPAN' /BY A FACILITY/SITE APPLICATION, FORM `A`,UNLESS ;URRENT FORMA' HAS BEEN FILED