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I STATE OF CALIFORNIA WATER RESOURCES CONTRCIOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY K ONE ITEM F-12 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE BlJ'B TANK REMOVELog FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES 0 NO Z I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SOSPECIFV ICI A. OWNERSTANKID# D B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS:- QDU Ab II. TANK CONTENTS IF(A.1), S MARKED,COMPLETE ITEM C.IF IRA),IS NOT MARKED,COMPLETE ITEM D. Qui} A Vf 1 MOTOR VEHICLE FUEL Eff2 PETROLEUM B. C. UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑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) 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CA.S.# Al JA CA.S.#: .III. TANK CONSTRUCTION MARK ONE IT M ONLY IN BOX A,B,C.&D A. TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 92112 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER I STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FlBERGUSS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FOP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR F-11 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING Be6 UNLINED ❑ 95 UNKNOWN ❑ LS UNING MATERIALCOMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETH ENE WRAP ❑2 OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC w 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 TYPEA 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A 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 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%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. 1,A P S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 6 5 GROUND WATER MONITORING WELLS J*,[� P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 1 NONE P 4 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAS USED(MO/VR) 2. ESTIMATED OU TITY OF 3. WAS T K FILLED WITH SUBSTA INGIN E A RAL? ❑YES [:] NO I GALLONS i THIS FORM HA BEEN COMPLETED UNDER PENALTY OF P RJURY,AND TO THE BEST OF MY KNOWL DGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY �CCOU�NTTYYY## JURISDICTION# AGENCY# FACILITY ID# TAANNK ID# CURREFLT LSO ALAG�FACILITY3'j APPVVyO BY NAMEJ PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE I PERMIT EXPIRATION DATE l CHECKp PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTp BY: FORM B(3-7-9B) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY