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r Swl�F' <br /> STATE OF CALIFORNP WATER RESOURCES CONTE IWOARD <br /> FORM 'B': UNDERGROUND STORAGE TANK PRUGRAM <br /> TANK PERMIT APPLICATION INFORMATION <br /> TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> 1 NEW PERMIT 3 RENEWAL PERMIT C4_1�CHANGE OF INFORMATION E]7 PERMANENTLY CL SED TPf <br /> MARK ONLY <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 08 TANK REMOVEDP-Q. <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: qo (4 o �$Z FARMTANK-YESM NRI[N ZIP <br /> 14 1-1.1 <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY n-y <br /> A. OWNERS TANK ID 4 B. ANUF <br /> MACTURED BY: L)lk, <br /> M 6 <br /> Zp C. YEAR INSTALLED TANK C L CAPACITY IN GALLONS: <br /> W <br /> II. TAtIKAONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKEDX <br /> OMPLETE ITEM D. co <br /> A. I MOTOR VEHICLE FUEL F-] 2 PETROLEUM C. 0 1 UNLEADED E] 2 LEADED 3 DIESEL <br /> 4 OIL '7'. <br /> 3 CHEMICAL PRODUCT [ VI PRODUCT El 4 GASAHOL 5 JET FUEL 6. AVIATION GAS <br /> F-1 5 HAZARDOUS BO EMPTY [-] 95 UNKNOWN 0 WASTE 7 METHANOL 0 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D, IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S. <br /> All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF 0 XUBLE WALLED El 3 SINGLE WALLED WITH EXTERIOR LINER E] 95 UNKNOWN <br /> SYSTEM EK,F-P SI &E WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> I STEEL/IRON <br /> 2 STAINLESS STEEL 3 ABERI ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC F <br /> B.TANK, F-] 5 CONCRETE F-1 6 POLYVINYLCHLORIDE F-1 7 ALUMINUM ❑8 IW%METHANOL COMPATIBLE FRP <br /> MATERIAL 9 BRONZE 141 GALVANIZED FEEL [:j 95 UNKNOWN 0 99 OTHER <br /> F-] I RUBBER LINED 2 ALKYD LINING 0 3 EPDXY LINING 4 ENOLIC LINING <br /> 6 UNLINED <br /> C. INTERIOR 5 GLASS UNING W95'UNKNOWN <br /> LINING 0 El <br /> ISUNING MATERIAL COMPATIBLEWITH 100%METHANOL? YES [:] NO 99 OTHER <br /> D. CORROSION ❑ 1 POLfETHLENEWRAP 2 TAR OR ASPHALT 3 INYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> E:] <br /> PROTECTION 5 CATHODIC PROTECTION T NONE V95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE AtU)l SUCTION A U 2 PRESSURE A 3 GRAVITY A 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A. U 3 LINED TRENCH A(U_)95 UNKNOWN A U 99 OTHER <br /> A U I STEEIJIRON A U 2 STAINLESS STEEL A. U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE <br /> C. MATERIAL A U 5 ALUMINUM ACONCRETE A U 7 STEEL CLAD WIFRP A U 8 100%METHANOL COMPATIBLE FRPA U 9 GALVANIZED STEEL A 05 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> S 1 VISUAL CHECK up S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 5 4 ELECTRONIC MONITOR P S 6_61HOUNO WATER MONITORING WELLS <br /> PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MQ/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH <br /> " <br /> SUINERT MATERIAL? D=YES=[D:] NO <br /> El <br /> GALLONS <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> 1 1 171 El I KE� Kte4l [0:1 o I �E <br /> CURRENT LOCAL AGENCMY [LITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> u A✓5 c/o <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHIECK# PERMIT AMOUNT SURCHARGE AMT. FEE COD <br /> E RECEIPT# BY:- <br /> FORM B(3-1-BEI) THIS FORM MUST BE ACCOMPANIES,dY A FACILITY/SITE APPLICATION, FO RM 'A',UNLESS A"TRENT FORM'A' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />