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STATE OF CALIFORNIP WATER RESOURCES CONTRO' 70ARD FORM `B': UNDERGROUND STORAGE TANK PROC'RAM TANK TANK PERMIT APPLICATION INFORMATION I A COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMR 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NOO��------///----�++ z I. TANK DESCRIPTION COMPLETE/ .� ALL ITEMS-IF UNKNOWN—SO SPECIFY Wk IC A. OWNERS TANK IDR / �,J�_j3 B. MANUFACTURED BY: C. YEAR INSTALLED '/�' D. TANK CAPACITY IN GALLONS W 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. Ek'l MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. NLE UADED ❑ 2 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT F-1B.4 OIL 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 8 C.A.S.R C.A.S.#: =III. TANK CONST CTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF E&ft)ouBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLEWALLED ❑4 SECONGARYCONTNNMENT ❑ 99 0 ❑ 1 STEEUIiON ❑2 STAINLESS STEEL ❑3 FIBERGLASS STEB.CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER UNED ❑2 ALKYO LINING ❑ 3 EPDXY UNING ❑4 PHE14OUC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINEDF�q4`UMKNOWN ❑ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑ 990THER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VI P ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 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 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A 2 DOUBLE WALLED A U 3 LINED TRENCH A U %UNKNOWN A U 99 OTHER A U / STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLWIWLCHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U B 100%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 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION PS 3 VADOSE WELLS 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED,(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH NSUBSTANCE REMAINING IN GALLONS INERT MATERIAL? F]YES ❑ NO THIS FORM HAS BI COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED K SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION# AGENCY# FACILITY ID# TANK ID# � CURRENTLOCAL GENCY FACILITY 10# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMITAMOUNT SURCHARGEAMT. FEE CODE RECEIPT p BY: FORM B(3-7-8B) THIS FORM MUST BE ACCOMPANIE,- Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A —ARENT FORMA' HAS BEEN FILED _ j