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STATE OF CALIFORNI WATER RESOURCES CONTR( 30ARD 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 NEWPERMIT ❑3 RENEWALPERMIT 55 CHANGE OF INFORMATIONI� L✓J ❑ 7 PERMANENTLY CLO4TANKONE ITEM ❑ 2 INTERIMPERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVEDFACILITY/SITE NAME WHERE TANK IS INSTALLED: �v �, FARMTANK-YES❑ NIV I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 00 A. OWNERSTANKID# B. MANUFACTURED BY: cc C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 1,01f II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL f1 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&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,B D A. TYPE OF ❑ I DOUB.EWA3LED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM F�!-r2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER LSA I STEEUIRON ❑ 2 STAINLES3 STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FHP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 LINING F-13 EPDXY LINING ❑4 PHENOLIC LINING LINING F-15 GLASS UNING 6 UNUNED ❑95 UNKNOWN A- ' ❑ IS UNING MATERIAL COMPATIBLE WITHI METHANOL? ❑YES ❑ NO ©'99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORM 1 N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER j B. CONSTRUCTION A(Uj SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER j A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUMA 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOLCOMPATIBLEFRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER J/. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. ( P 8 1 VISUAL CHECK v 3 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS v 3 6 ELECTRONIC MONITOR P 3 5 GROUND WATER MONITORING WELLS J P 6 PREQSION TEST.Up : ] PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIMAED DATE LAST USED(MO/YR) 2. ESTIMAT D QUANTITY OF 3.W STANK FILLED WITH Mn US EMAINING IN T MATERIAL? ❑YES E]NO GALLONS THI FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KN WLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# � L y � � 0o CURB T LOCAL AGENCY FAC ITY ID# APPROVE BY NAME PHONE#WITH AREA CODE 8Ff, fL PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXP#UkTIOA DATE 1CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: A1v'll I FORM B(8-29-BB) THIS FORM MUST BE ACCOMPAN Y A FACILITY/SITE APPLICATION, FORM `A',UNLESS A RENT FDRom, HAS BEEN 1 DATA PROCESSING COPY