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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD °• .; FORM B': UNDERGROUND STORAGE TANK PROGRAM TANK / TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING I ORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 REN ALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 1 AMEND PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED If FACILITY/SITE NAME WHERE TANK IS INSTALLED: Mdo ZA&�4FARM TANK-YES❑ NO Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY ef 10 A. OWNERS TANK ID# #4 B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: W II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. (D A ❑ 1 MOTOR VEHICLE FUEL E�t2 PETROLEUM SfA.,J4) R. C. ❑ 1 UNLEADED ❑2 LEADED IESEL ❑3 CHEMICAL PRODUCT ❑4 OIL I 1 PRODUCT ❑4 GASAHc) ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAYARDOUS ❑ 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.# AjhC.A.S.W ixigt All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A.B,C, D A TYPE OF ❑ I DOUBLE WAILED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM AT ❑4 SECONDARY CONTAINMENT ❑99 OTHER /IRON ❑2 STAINLESS STEEL IJ ' FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK 5 CONCRETE ❑6 POLYVINYLCHLORIDE ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZEDSTEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑ 2 AUODUNING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNUNED ffje<KNOWN ❑IS UNING MATERIAL COMPATIBLE WITH 1Oft METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINY WRAP 4 F18MBLASS REINFORCED PLASTIC PROTECTION ❑5 CATFIMCRpTECTION ❑91 14DNE N 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A LA I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5ALUMINUM A BCONCRETE A U ISTEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 5 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. 0P1 :paoi VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSEWELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN 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 4 ] ^ SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO GALLONS THIS FORM HAb BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3 9 = = 10 b I 1� 3 0 v f CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE 9/ PERMIT NUMBER PERMIT APPROVAL DATE RMIT 1EXPIRATIONfiATE CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: L FORM B(3-7-BB) THIS FORM MUST BE ACCOMPANIED BYA FACILITY/SITE APPLICATION, FORM 'A',UNLESS&LUZENT FORMA' HAS BEEN FILED DATA PROCESSING COPY