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STATE OF CALIFORNIA WATER RESOURCES CONTROL -')ARD FORM `B': UNDER-GROUND STORAGE TANK PROGRAM ; L� TANKTANK PERMIT APPLICATION INFORMATION } ° COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z IC MARK ONLY NEW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL SED TANK ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED /� N FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ A I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY \\ A. OWNERSTANK ID# 2�- L� 223 B. MANUFACTURED BY: IVv- C. YEARINSTALLED IT7E) D. TANK CAPACITY IN GALLONSZ ISCSO IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 2ri MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C ❑ 1 UNLEADED �2�LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT ❑4 OIL �rPRODUCT ❑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) 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.W III. TANK CONSTRUCTION MARKONE ITEM ONLYIN BOXAB,C,&D A.TYPE OF ❑ 1 DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ?Ky SINGLE WALLED ❑4 SECONDARY CONTAINMENT El 99 OTHER �T(/RJ.BT�kINIDN ❑2 STAINLESS STEE 3 RBERGLA ❑4 STEEL CIADWIFlBERGLASS REINFORCED PLA ST IC B.TANK !!❑5 CONCRETE 1--]6 POLYVINYL CHL NUM ❑B 1DO%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑W OTHER F-1I RUBBER UNED E]2 ALKYD LINING ❑ 3 EPDXYUNING F-14 PHENOLIC LINING C. INTERIOR LINING ❑5 CUSS LINING ❑6 UNLINED �95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLEWITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TARORASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS 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 TYPETION A 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A&1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER AON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A®95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR 8 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. �L P S 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS JJ P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF &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# 3= = = I 0 (D 53 O2 0-1 CURRE T OCAL AGENCY FACILITY ID 4Y NANj PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL Orn PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: ARE FORM B(629-88) THIS FORM MUST BE ACCOMPANIEDMY A FACILITY/SITE APPLICATION, FORM `A',UNLESS NT FORM'A' HAS BEEN FILED ,J DATA PROCESSING COPY