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STATE OF CALIFORNIA* WATER RESOURCES CONTROARD FORM 'B': UNDERGROUND STORAGE TANK PRO AM qA TANK TANK PERMIT APPLICATION INFORMATIONCOMPLETE A SEPARATE FORM WITH THE FOLLOWING INF RMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: �j �, MQ FARMTANK-YES[ NO Z L TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY I IC! A. OWNERS TANK IDN — ?> B. MANUFACTURED BY: V I�+L C.YEAR INSTALLED U n,J D. TANK CAPACITY IN GALLONS: I C) v 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. C3 A f7 I MOTOR❑3 CHEMICALPRODUCTCLE ❑ 2 POET LEU M B 1 PRODUCT C ❑ 1 UNLEADED ❑ 2 LEADED .; ❑ 3 DIESEL ❑ 4 GASAHOL ❑ 5 JET Fu i ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.N w C.A.S.N: x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,s D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASIIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUM UM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN 99 OTHER ❑1 RUBBERUNED ❑2 ALKYDUNING ❑ 3 EPDXYLINING ❑ 4 PH CLINING C. INTERIOR LINING ❑5 GLASS LINING ❑6 UNLINED 95 UNKNOWN ❑ ISUNING MATERIALCOMPATIBLE WITH 100KMETHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHUNE WRAP ❑ 2 TARORASPHALT ❑ 3 VI RAP ❑ 4 F18ERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLEWALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM ASL 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A 1(;,'/)95 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. n P 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS 11 P 8 6 PRECISION TESTING P S 7 PRESSURETESTING4f!111 NONE- P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTL CLOSED IN PLACE 1. ESTIMATED DATE LAST USE ( /YR) 2. ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES E] NO THIS FORM HAS BEE14 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 M JURISDICTION# AGENCY N FACILITY ID N TANK ID# CURRENT LOCAk AGENCY FACILITY ID N APPROVED BY NA PHONE#WITH AREA CODE IL t'L � PERMIT NUMBER PERMIT APPROVAL OPSE P MIT PIRATION DhTE CXECKM PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: KI FORMB(34-88) THIS FORM MUST BE ACCOMPAM YAFACILITY/SITE APPLICATION, FORM 'A',UNLESS A JRRENT FORMA' HASBEENFILED DATA PROCESSING COPY