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STATE OF CALIFORba WATER RESOURCES CONT BOARD QO FORMB': UND RGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INF MATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED , I FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARMTANK-YES❑ NO I. 10 TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IDN , B. MANUFACTURED BY: C. YEAR INSTALLED ! D. TANK CAPACITY IN GALLONS: 3oB CA) 11. TANK C NTENTS 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 DIESELLn ❑3 CHEMICAL PRODUCT ❑ 4 OIL 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.q. KIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ 1 DOWALLED F-]3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN ,PUSYSTEM SING WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3FIBERGLASS ❑ 4STEELCIAD W/RBERGLSS REINFORCED PLASTIC S.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER UNED ❑2 3APIBUNING ❑3 EPDXY LINING ❑4 PHENOLIC UNING C. INTERIOR ❑5 GLASS LINING UNLINED ❑ 95 UNKNOWN LINING ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? DYES ❑ NO ❑99 OTHER_ D.CORROSION ❑11YETHLENEWRAP ❑ 2 TARORASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION Z 5 CATHODIC PROTECTION ❑91 NONE ❑95 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 99 OTHER CJ (� 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 i STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U S CONCRETE A U 7 STEELCLADW/FRP A U R 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A U 5 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. C Q;' P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS V\C� P S 6 PRECISION TESTING P S 7 PRESSURETESTING P 91 NONE P S 95 UNKNOWN P 5 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1, ESTIMATED DATE LAST USE ( /YR) 2. ESTIMATED OUANTITY OF 3, WAS TANK FILLED WITH /lI// SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E]YES [:] NO THIS FORM HAS BEON 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# JURISDICTION# AGENCY R FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DA PERMITE)�ATIA CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY. FORMB(3-7-88) THIS FORM MUST BE ACCOMPANIE67 A FACIUTYISRE APPLICATION, FORM'A',UNLESS A RENT FORMA' HASBEENFILED DATA PROCESSING COPY