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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAMA TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - - MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 RMANENTLY CLOSED TANK ONE ITEM 1-12 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED 6 9 FACILITY/SITE NAME WHERE TANK IS INSTALLED: J Ll 750 hly±-�- ,Zy, , FARMTANK-YES❑ NO UZ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY Ili A. OWNERS TANK ID# ' I B. MANUFACTURED BY: C. YEAR INSTALLED 1 7 V D. TANK CAPACITY IN GALLONS: 000 II. TANK CONTENTS IF(Al),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. Wh A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL 3 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,A D A TYPE OF ❑1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑2 SBIGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑1 SIEBUIRON 2 STAINLESS STEEL F] 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC R.TAN( ❑5 CONCRETE POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE 10 , LVANIZED S1Ea ❑95 UNKNOWN ❑99 OTHER C INTERIOR ❑ 1 RIBBER UNED ❑2 NING ❑3 EPDXY LINING ❑4 PHENOLIC LINING UNNG ❑5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%M ? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TABOR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U INYINDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED !!)Sul 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A 3 POLYVINYL CHLORIDE(PVC) A U 4 RBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U STEELCLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 THER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECOND ,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. FP 8 1VISUALCHECK P S 2 INVENTORY RECONCILIATION P 8 3VADOSE WELLS P 8 LECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS PS 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 8 95 NNKNOWN P S 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 SUBSTANCE REMAINING IN DALL INERT MATERIAL? [—]YES ONO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF Y KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3 � 5 11 lo 161010111 CURRENT LOCAL AGENCY FACILITY IAPPROVED BY NAME PHONE#WITH AREA CODE i9-RN E I D# i> PERMIT NUMBER PERMIT APPROVAL DATE PE IT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORMB(6-29-88) THIS FORM MUST BE ACCOMPAIS NLE AFACILITY/SITE APPLICATION, FORM 'A',USSA NT FORM'A' HAS BEEN FILED / DATA PROCESSING COPY