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STATE OF CALIFORNIA WATER RESOURCES CONTROL OARD FORM B': UNDE&OUND STORAGE TANK PRO AM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. MARK ONLY ❑I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CL K ICI ONE ITEM [-]2 INTERIM PERMIT ❑1 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVE FACILITY/SITE NAME WHERE TANK IS INSTALLED: 2 �, Au j G1h - FARM TANK-YESEV NO ❑ 1 N - I. TANK DESCRIPTION COMPLETE ALL ITEYS-IF UNKNOWN—SO SPECIFY /��7(� co A. OWNERS TANK 10 N B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 0 II. TANKp6NTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. Eo 1 MOTOR VEHICLE FUEL ❑2 PETROLEUMC. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT E] D.1 OIL /IPRODUCT ❑ 1 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑60 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 A CAS.Y CA.S.N: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOER,B,C,AD A TYPE OF ❑ I DDUBI£WAllH) ❑3 SINGLE WALLED WITH DONOR LINER ❑95 mm" SYSTEM ❑2 SINGLEWAUBD ❑/SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUMON ❑2517AINES6 OR ❑3 FIKAGIASS ❑1 STEEL CUD W/RBFRGUSS REINFORCED PLASTIC B.TANK ❑5 CONDIETE ❑6 PDLYVIN/L CNLOPoDE ❑7 ALLMUM ❑6 1009i METHANOL CDWATIBLE FRP MATERIAL. . ❑9 BRJIIff ❑ 10 GALYANZEO SIBS ❑%LNKFIOYM ❑99 OTHER C.INTERIOR ❑I RUM""® ❑2 AUIYDUNING ❑3 EPDXY LINING ❑!PHENOUCUNNG LINING - ❑5 GUSS I WNG ❑6 UNLINED ❑95 UNI Nom ❑ISUMNGMATERALCOMPATIBLEMN 00%METHANOL ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYEDIFNEWRAP ❑2 TAR ORASRALT ❑3 VWLWMP ❑1 RBERGLASSREWORCEOPI.CM PROTECTION ❑5 GTHODCPRDTECTDN ❑91 NONE ❑95 UN NOBB ❑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 U 95 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 A U 95 UNKNOWN A U 99 OTHER A U 1 S7EEL/IRON A U 2 STAINLESSSIEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FIBERGLASSNPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/INP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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 A I VISUAL CHECK P N 2 INVENTORY RECONCIUATKW ■ i 3 VADOSE WELLS P B 4 ELECTRONIC MONITOR P i s GROUNDWATER MONITORING WELLS P i 6 PRECIS10NTES7ING P i 7 PRESSUflETESTING ■ i B7 NONE P i 95 UNKNOWN P i 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FLL1ED WITH SUBSTANCE REMAINING W GALLONS WERT MATERIAL? ❑YFS ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PLANTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY NJURISDICTION N AGENCY N FACILITY ID N TANK ID N = = = I I I A CURRENT LOCAL AOENCY FACILITY IDI APPROVED BY MAYS PHONE F WITH AREA CODE L� PERMIT NUMBER PERMITAPPROVAL DATE PERMIT IRATION DATE CHECKS PERMIT AYOUM RCHARGE AMT. FEE CODE EIPTF BY: /ORMB(6-29-86) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SfTE APPLICATION• FORM 'A',UNLESS A CURRENT FORM'W HASBEENFILED DATA PROCESSING