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STATE OF CALIFORNIA WATER RESOURCES CONTROL "()ARD FORM `B': UNDERGROUND STORAGE TANK PROG"AM qA TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3J FARM TANK-YES❑ NO IZ 1. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 10 A. OWNERS TANK ID# B. MANUFACTURED BY C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Hro GA1 II. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. N A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. [::] I UNLEADED 2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 524 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.#: V1 A KIII. TANK CONSTRUCTION MARK ONE AM ONLY IN BOX A,B.C,&D A TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM �2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEBUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE 6 POLYWNYL CHLORDE ❑7 ALUMINUM E]8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN [:)99 OTHER C. INTERIOR ❑ 1 RUBBERUNED ❑2/kffDLINING ❑3 EPDXYLINING E]4 PHENOUCUNING LINING ❑5 GLASS UNING li�ri UNLINED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLEMTH IDA METHANOL' ❑YES ❑NO ❑99 OTHER D CORROSION I PROTECTION 5 CATHODICPREOWECTION 91TNONE ASPHALT ❑3 UNKNOWNP ❑❑99FOTHE�IBERGUSS REINFORCED PLASTIC IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE AU t SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 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 KPVC) A U 4 FIBERGLASS PIPE C.MATERIAL A U S ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 195 UNKNOWN A U 99 OTHER I LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING09 7 PRESSURETESTING P B 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST GALLONS SED(MO/YR) 2. ESTIMATED QUANTITY F 3.WAS TAN F, LED WITH SUBSTANCE RE IN INER M T L? ❑YES E] NO THIS FORM HAS EN COMPLETED UNDER PENALTY OF PERDU AND TO THE BEST OF MY KNOWLED E IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CU ENT L CAL AGECY FACILITY ID# APP OV BY NQI / PHONE p WITH AREA CODE Lem . PERMIT NUMBER PERMIT APPRovAL!dATE I PERMIT_EXPIRATION DATE CHECK M PERMIT AMOUNT SURCHARGE AMITY 8 SFEE CODE aECEIPT# BY: FORMS(34-88) THIS FORM MUST BE ACCOMPARB:T/BY A FACILITY/SITE APPLICATION, FORM 'A',UNLE$swftRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY