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vTATE OF CALIFORPO WATER RESOURCES CONT BOARD FORM B': UN RGROUND STORAGE TANK PR GRAM TANKTANK PERMIT APPLICATION INFORMATION m l COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑7 PERMANENTLY=_,z ONE ITEM ❑ 2 INTERIM PERMIT F-] 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3 S ST FARM TANK-YES 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I C) A. OWNERS TANK ID# In 12-- B. MANUFACTURED BY: C.YEAR INSTALLED o�L I D. TANK CAPACITY IN GALLONS: CA) II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 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 8 C A.S.# C.A.S.#: x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM 2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ��-�II/11 STEEUI`ION ❑2 STAINLESS STEEL F-13 FIBERGLASS El STEEL CND W/FIBERGLASS REINFORCED PLASTIC MATERIAL LJ - & CONCfiEE]`TE 6 POLYNNYL CHLORIDE F-17 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑22AALKYD LINING F-13 EPDXY LINING ❑4 PHENOLIC LINING C.INTERIOR 5 GLASS LINING IXI 6 UNLINED ❑ 95 UNKNOWN LINING ❑ !"' ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOI? ❑YES ❑ NO ❑W OTHER D.CORROSION ❑ I POLYETHLENEWRAP ❑ 2 TARORASPHALT F-] 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:]5 CATHODIC PROTECTION .091 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A&99 OTHER J,Li V, B.CONSTRUCTION AWI SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A6)I1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A U 95 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 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING 0 8 91 NONE- P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEA COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NA AE(PRINTED B SIGNATURE) DATE LOCAL AGENCY US ONLY JU ISDICTION k AGE❑ FACILITY ID# TANK IO# FP, 13 3 ® 02 CURRENT LOCAL AGENCY FACILITY ID# PP Y NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL PERMITEKP ATIONDATE CK* PERMIT AMOUNT .SURCHARGE AMT. FEE CODE RECEIPT# BY: 7-e9I THIS FORM MUST BE ACCOMPANfMYAFACILITY/SITE APPLICATION, FORM'A',UNLESSAVARENT FORMA' HASBEENFILED DATA PROCESSING COPY