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STATE OF CALIFORNI/ WATER RESOURCES CONTRO' "OARD FORM 'B': UNDERGROUND STORAGE TANK PROMAM ; TANK PERMIT APPLICATION INFORMATION (�'�' TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. G MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 1 PERMANENTLY CLOSED TANK IO ONE ITEM F-1 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED /O< FACILITY/SITE NAME WHERE TANK IS INSTALLED: 750 FARMTANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID N 2 B. MANUFACTURED BY: kN W C.YEAR INSTALLEDukd D. TANK CAPACITY IN GALLONS: OD IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. F-11 MOTOR VEHICLE FUEL F-] 2 PETROLEUM B. C. Ej 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT F-14 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS EV5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN J2 WASTE ❑T METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAMEOF HAZARDOUS SUBSTANCE STORED&C.A.S.N Q N,e- C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,&D A TYPE OF ❑�1 DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER E]95 UNKNOWN SYSTEM L'J`SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER DR/, STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CND W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8190%MEfHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING n 4�PHENOUC LINING 5 GLASS LINING ❑6 UNLINED 95 UNKNOWN C.INTERIOR Lrr�:/ LINING ❑ ❑ IS LINING MATERIAL COMPATIBLE MTH 1VA METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 NYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION L]91 NONE VuNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE 5 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE Jf 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 A U 91 NONE C. MATERIAL A U 5 ALUMINUMA J�.�B CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL fl/.�Y.�/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. S 1 VISUAL CHECK P 6 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS le P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 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 j SUBSTANCE REMAINING IN GALLON! INERT MATERIAL? [-]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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION# AGENCY# FACILITY ID# TANK ID# EE lolo I l 1 15- 12- 1 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME n PHONE N WITH AREA CODE � or( C a W PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK♦ PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: FORMB(6-29-66) THIS FORM MUST BE ACCOMPANIEd'FTA FACILITY/SITE APPLICATION, FORM `A',UNLESSA LL%RENT FORMA' IMBEENFIED DATA PRO SSING COPY �'