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STATE OF CALIFORNIt WATER RESOURCES CONTROV—OARD FORM 'B': UNDER-GROUND STORAGE TANK PRObitiAM TAN t TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK.: MARK ONLY ❑ 1 NEW PERMIT 7 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION [:]7 PERMANENTLY CL K ONE ITEM 2 INTERIM PERMIT Fl 4 AMEEN/DEDPERMIT 6 TEMPORARY TANK CLOSURE E:]B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: -TSS :T, DO 1AA .S fly FFARMTANK-YESD NO z I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY yfLO 10 A. OWNERS TANK ID# # ; B. MANUFACTURED BY: 5'r 3 C. YEAR INSTALLED I _1 B d D. TANK CAPACITY IN GALLONS: 2Q 6'Q II. TANK CONTENTSIF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. N A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. 1 UNLEADED E] 2 LEADED ERr3 DIESEL 3 CHEMICAL PRODUCT D 4 OIL B. PRODUCT 4 GASAHOL 5 JET FUEL [:]6 AVIATION GAS W 5 HAZARDOUS E]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 IS,CA.S.R C.A.S.#: .III. TANK CON RUCTION 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 2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER F-11 STEEUIRON 2 STAINLESS STEEL F-13RBERELAS9 EIK4STEEL GLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK F.1 5 CONCRETE 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM 8 109%METHANOL COMPATIBLE FRP MATERIAL El 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER C. INTERIOR ❑ 1 RUBBER UNED 2ALKYD LINING 3EPDXY LINING / NOUC LINING LINING ❑5 GLASS LINING 6 UNLINED 95 UNKNOWN 6LINNG MATERIAL COMPATIBLE WITH LOB%METHANOL? YES [:] NO E]99 OTHER D. CORROSION [—]YETHLENEWRAP 2 TAR OR ASPHALT F-13 VINYLWRAP 7 4 FIBERGLASS REINFORCED PLASTIC PROTECTION V5 CATHODIC PROTECTION 13 91 NONE ❑95 UNKNOWN [:]99 OTHER IV. PIPING INFORMA ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALLED A V 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C.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 A U 95 UNKNOWN A U 99.OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR $ FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS 6 PRECISION TESTING P 8 7 PRESSURETESTING P 8 91 NONE P 8 95 UNKIJOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF GALLONS 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN 1 INERT MATERIAL? E:l 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 ID# 6 10 o 01 10 / CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE r PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT I SURCHARGE AMT. FEE CODE _RECEIPT# \d FORM B(3-7-99) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS RRENT FORMA' HAS BEEN FILED ..