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STATE OF CALIFORNS WATER RESOURCES CONTRWOARD FORM 'B" UNDERGROUND STORAGE TANK PRO RAM N TANK TANK PERMIT APPLICATION NFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWI INFORMATION FOR EACH TANK. z 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDT�K ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED Ca FACILITY/SITE NAME WHERE TANK IS INSTALLED: O/ V FARMTANK-YESE NO ❑ IV C7) 1. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Q) A. OWNERS TANK ID# U B. MANUFACTURED BY: /L CA C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: //DO- 11. 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 ❑ 3 CHEMICAL PRODUCT ❑ 4 OILIBJ F-] 1 PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS F]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 8 C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXAS,C,BD A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STESUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PIAS TIC B.TANK ❑5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 AL MINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL Z95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXY UNING ❑4 PHENOLIC UNING C.INTERIOR 5 GLASS LINING 6 UNLINED UNKNOWN LINING F] ❑ ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 990THER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TARORASPHALT ❑ 3 VI P ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE D4 UNKNOWN ❑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 A 165 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 (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 ALUMINUM A 9,6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS i P S 6 PRECISION TESTING P S 7 PRESSURETESTING S 91 NONE P 95 UNKNOWN P 6 99 OTHER VI. INFORMATION ON TANK PERMANENTL CLOSED IN PLACE I 1.ESTIMATED DATELAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS FILLEDWITH SUBSTANCE REMAINING INGALLONS INERT MATERIAL? YES [1] NO I 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# TANK ID# 1-7 � nI = = I 1 1 46 CURRENT LOCALKNCY_FACILITY ID# APPROVED By NAME PHONE#WITH AREA CODE Ir PERMIT NUMBER GEC�.L(� PERMIT APPROVAL DATE PERMIT EXPIRATION DATE I CHECK# PERMIT AMOUNTSURCHARGE AMT. FEE CODE RECEIPT# BV: Agiiiil FORM B(6-29-B6) THIS FORM MUST BE ACCOMP IED BY A FACILITYYSITE APPLICATION, FORM 'A',UNL A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY