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STATE OF CALIFORNIA WATER RESOURCES CONTROI 1ARD FORM 'B': UNDEIMROUND STORAGE TANK PROG-RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. G MARK ONLYNEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT F74 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO ji I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A A. OWNERS TANK ID# �L) - 2-& B. MANUFACTURED BY: W C. YEAR INSTALLED �O�' D. TANK CAPACITY IN GALLONS. 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE TEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNL D ❑ 2 LEADED E] 3 DIESEL F-13 CHEMICAL PRODUCT F-] 4 OIL ❑ 1 PRODUCT ❑4 SAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ZO 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.#: III. TANK CONSTRUCTION MARK ONE ITE o Y N eo ,c, A.TYPE OF 1 DOUBLE WALLED 3 GL ALLIED H EXIERI INER 95 UNKNOWN SYSTEM SINGLE WALLED 4 BE NDA MAIN 99 OTHER ❑ 1 N 'To i LESS ❑3 F ❑a STEEL CLADWIFIBERGlASS REINFORCED PLASTIC B.TANK ❑5 PETE 6 POLYV LCHLORIDE ALU UM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 B ZE 1 ALVANIZE STEEL UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1RUBB LINED IALKYDU NO 3EPDXYLINING ❑ 4 PHENOLIC LINING LINING ❑5 GLASS LNING 6 U ❑95 UNKNOWN ❑ IS LINING MATE COMPATIBL LTH 1 MET L? YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 PO LENEWRAP TAR HALT F-13 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED RASRC PROTECTION CATHODIC PROTECTION NE ❑95 UNKNOWN ❑ 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 i 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 STEELARON A U 2 STAINLESS STEEL 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 STEELCLADW/FRP A U 8 100%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 S VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S e PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE 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(PRINTE0851GNATURE) DATE "ll LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# ME I dol I cl ol 3 1S CURRENT LOCAL AGENCY FACILITY IDN NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DAlY PERMIT EXPIRATION DATE CHECKN PERMITAMOUNT SURCHARGEAMT. FEE CODE RECEIPT BY: FORM R IS-29-55, THIS FORM MUST BE ACCOMPANIEM A FACILITY/SITE APPLICATION, FORM 'A',UNLESS AL'OISRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY