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STATE OF CALIFORM WATER RESOURCES CONTR(� _ARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM ;mom TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. O MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 RMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE • R TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: f-yL p -i - FARMTANK-YESL114 NO ❑ N I"a I. TrC NK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY / Ca OWNERS TANK IDR B. MANUFACTURED 13Y: U[�— YEARINSTALLED � t-- D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL GASAHOL 05J F I PF ODUCT ET FUEL ❑6 AVIATION GAB ❑ 5 HAZARDOUS ❑ BO EMPTY 5 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.R C.A.S.R: III, TANK CONSTRUCTION MARKONE ITEM ONLY INBOXA,B,C,BD A. TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER r ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FlBERqASf ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PIABTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ MINUM ❑9100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑i RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXY LINING ❑4 PH IC LINING C. LININ INTERIOR 5 GLASS UNING ❑6 UNUNED UNKNOWN LINING ❑IS UNING MATERIAL COMPATIBLE WITH 100%MEDLANOL? Y ES ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2TAR OR ASPHALT WRAP ❑ 4 FIBEIIGlASS REINFORCED PLASDC PROTECTION 5 CATHODIC PROTECTION ,❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, 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 A 95 UNKNQW4UA U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 95 UNKNOWN U 99 OTHER A U / STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U B A UT STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U NKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P 8 4 MONITOR P 6 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S ] PRESSURE TESTING P S 91 NONE 8 95 UNKNO P S 99 OTHER VI. IN MATION ON TANK PERMANENTLY CLOSED IN PLACE MATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANKFlLLED WITH SUBSTANCE REMAINING IN INERT GALLONS MATERIAL? ❑YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION B AGENCY B FACILITY IDR TANK ID R CURRENT LOCAL §I(CT FATY,J6tZ APPRO ED BY NAME / PHONE R WITH AREA CODE 17 I 1PERMITNUMBER PERMR APPROVAL DATE PEP IT EXPI TION DATE CHECK• PERYR AMOUNT SURCHARGE AMT. FEE CODE RECEIPT BY: T� FORM B(6-29;,6)v IS FORM MUST BE ACCOMPANI A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORMA' HAS BEEN FILED f-" DATA PROCESSING COPY