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STATE OF CALIFORNIe WATER RESOURCES CONTR OARD FORM 'B': UNDERGROUND STORAGE TAPR0 R NK AM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: Fol, TOIyT S, FARM TANK-YESED110 ❑ I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-410 SPECIFYz 10SPECIFYz A. OWNERS TANK ID# Wh I B. MANUFACTURED BY: (q, C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: /D 00 b 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. W Q A. EEll MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED EplLEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL c/ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑SOTY 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.#: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C,&D A TYPE OF ❑ 1 DOUBLE WAllB3 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2-25SINGUE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 3�"R"' ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WRIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOLGOMPATIBLEFRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL [e95 UNKNOWN ❑99 OTHER C.INTERIOR F-11 RUBBER LINED 2 ALKYD UNING ❑ 3 EPDXYLINING 4 PHENOLIC UNING LINING ❑5 GLASS UNING ❑6 UNLINED F�495 UNKNOWN ❑ISLINING MATERIAL COMPATIBLEWITH IOD%METHANOL? YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑�3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:]5 CATHODIC PROTECTION ❑91 NONE M%UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE !o U 1 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 g>95 UNKNOWN A U 99 OTHER A U 1 STEELPRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A GU 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. 7 P S 1 VISUAL CHECK ©S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS PCS) 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONEP S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED IMO/VRI 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS E] ❑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# TANK ID# 39 I oo / -)- F 000 / CURRENT LOCALA ENCYFACILI ID# APPROVED YNAMP� PHONE#WITH AREA CODE W6 96 PERMIT NUMBER AA/ PERMIT APPR7OVAL DA7T9 �jJ OOP�E�`JJ((RJJMIT EXPIRATION DATE I J� Sp CHECK# PERMIT AMOUNT SURCHARG AMT. FEE CODE RECEIPT# BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANI Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS MPENT FORMA' HAS BEEN FILED DATA PROCESSING COPY