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STATE OF CALIFORN$ WATER RESOURCES CONTRopOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANKTANK PERMIT APPLICATION INFORMATION g . COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEI.PERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM IC—dI,`,INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED v FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARMTANK-YES❑ NO Z 1® I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SOSPECI A. OWNERS TANK IDK I B. MANUFACTURED BY: KTcK_l C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: IL TANK C94TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. jh. A. 1 MOTOHVEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED IESEL F-1 3 CHEMICAL PRODUCT F—] 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.R: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,S,C,A D A TYPE OF ❑ 1 WEED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM fL1.a_K LE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8188%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 All—UNING ❑3 EPDXY UNING ❑4 PHENOLIC UNING C. INTERIOR ❑5 GLASS LINING NLINED ❑95 UNKNOWN LINING ❑ IS UNING MATERIAL COMPATIBLE WITH 100% ETHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑'1 POLYETHLENEWRAP TAR OR ASPHALT ❑3 VINYLWRAP ❑4 RBERGUM REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMAT ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A Ph SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PAIC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD WYFRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A D5 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. yy P 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER ,RR VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST SED 1 2. ESTIMATED QUANTITY OF GALLONS 3.WAS TANK FILLED WITH ( /Y SUBSTANCE REMAINING IN 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID N TANK ID# oo71 oo � � CURRENT LOCA AGENCY FACILITY IDJ{/ APPROVED BY NA NE M WITH AREA CODE S PERMIT NUMBER PERMIT APPROVAL DATE ERMIT PkPIRATIOND MIE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: APPLICATION, FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIE A FACILITY/DIATAPROCESS PROCESSING UNLESS A vu RENT FORMA' HAS BEEN FILED oP