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STATE OF CALIFORNO WATER RESOURCES CONTF*OARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION ` Q- COMPLETE A SEPARATE FORM WITH THE FOLLOWING I ORMATION FOR EACH TANK. .d MARK ONLY F-11 NEW PERMIT ❑ 3 RENEWALPERMIT CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REM mal FACILITY/SITE NAME WHERE TANK IS INSTALLS - 31 5, 3 FARMTANK-YES NO -y I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECI 10 A. OWNERS TANK ID a (/ B. MANUFACTURED BY C. YEAR INSTALLED D. TANK CAPACITY IN GALLON ' W II. TANK C NTENTS IF(A.1),4AARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL PETROLEUM B. CC..'❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL d ❑3 CHEMICAL PRODUCT F-] 4 OIL PRODUCT //) ❑4 GASAHOL ❑ 5 JET FUEL VIATION 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 y „/ 6 HAZARDOUS SUBSTANCE STORED&C.A.S.# - C.A.S.N: A /I/ All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D I DOUBLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN A. TYPE OF ❑ SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEBURON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGLASS REINFORCED PI-Ape B.TANK /S F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑1 AL M ❑81W%METHANOLCOMPATIBLEFRP MATERI ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER ❑ 1 RU813BTUNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIO 2) LINING ❑ 5 GLASS LINING ❑6 UNUNED UNKNOWN ❑IS UNING MATERIAL COMPATIBLE WITH 100%METHANO�� YES ❑99 OTHER D.CORROSI 1 POLYETHENEWRAP ❑2 TAR OR ASPHALT ❑3 VI P ❑4 FIBERGLASS REINFORCED PLASTIC /^ PROTECTION E]5 CATHODIC PROTECTION E]91 NONE UNKNOWN ❑ 99 OTHER IV. PIPING INFO NATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE(&l A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITYA U 99 OTHER (/ B. CONSTRUCTIO A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A UNKNOWN A U 99 OTHER /�//� A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPWE C. MATERIAL / �/ A U 5 ALUMINUM A U CONCRETE A U 7 STEELCLADW/FRP A U B 100%METHANOL COMPATIBLE FRP l/ A U 9 GALVANIZED STEEL A 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 I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S I VADOSE WELLS P 8 6 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING (1?s 91 NONE 45 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE . STIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH N may, SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? [-]YES 0 N THIS FORM HAS BEEN 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# ZW- FACILITY ID# y TANK ID# 3M 1 0 1 o 2' �1 rl I o C ENT LOCAL AGENCY FACILITY 10# A ROVE ME- PHONE#WITH AREA CODE 72�nr/� 3l S RMIT NUMBER PERMITAPPROVAy DATE PERMIT E%PIRATIO ATE CHECK# PERMIT AMO NT SURC GE AMT./A✓/ FEE CODE RECEIPT# BY: FORM B(3-7-86) THIS FORM MUST BE-ACC IED BY A FACILITY/SITE APPLICATION, FORMW,UNI.WMA CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COI `