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r, STATE OF CALIFOR WATER RESOURCES CONTO BOARD FORM `B': UN GROUND STORAGE TANK PROGRAM pA TANK PERMIT APPLICATION INFORMATION TANK ` COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. «" q MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED T NK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED UTA FACILITY/SITE NAME WHERE TANK IS INSTALLED: Q F 1 �Arl FARM TANK-YE8❑ NO z ,�Zp 1 G I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: (� C. YEAR INSTALLED U� D. TANK CAPACITY IN GALLONS: lip W II. TA9& ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A7),IS NOT MARKED,ebmPLETE ITEM O. 00 A. 1 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&C.A.S.# C.A.S.#: Kill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXA,B,C,A D A TYPE OF ❑ i l FIE WALLED ❑ 3 SINGLE WALLED NTH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SO&EWAULED ❑4 SECONDARYGONTAINMENT ❑99 OTHER I STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 IDA METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ JA GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING /P ENOUC LINING LINING C. INTERIOR ❑5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? [::]YES ❑ NO ❑99 OTHER D. CORROSION ❑I POLYErHENEWRAP ❑2 TAR OR ASPHALT ❑3 IWLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE V95 UNKNOWN ❑99 OTHER IV. PIPING INFORM ION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 0 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A V,99 OTHER B.CONSTRUCTION A U 1 SINGLEUWALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 F18ERGLASSPIPE C. MATERIAL A U 5ALUMINUM A 6CONCRETE A U 7STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U), 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. S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 6 91 NONE- P 6 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED GATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY ILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER �� PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODEEIPT# BY: RECG✓� FORMS(3-7-88) THIS FORM MUST BE ACCOMPANILu aY A FACILITY/DATA PLROCESS NOGG 'K,UNLESS ,.,,URENT FORMA' HAS BEEN FILED