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� M STATE OF CALIFORNI�""'% WATER RESOURCES CONTRC" 9OARD FORM B': UNDERGROUND STOR i TANK PRO RAM TANK TANK PERMIT APPLICATION INFORMATION ` COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. "°� z is 1 NEWW PERMIT 3 RENEWAL PERMIT E� 5 CHANGE OF INFORMATION PERMANENTLY CLOSED TANK MARK ONLY ❑ ONE ITEM a 2 INTERIM PERMIT 4 AMENDED PERMIT ' $TEMPORARY TANK CLOSURE F2 B TANK REMOVED rya FACILITY/SITE NAME WHERE TANK IS INSTALLED: -f fl 0 ,I FARM TANK-YES NOFA- �0 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Q A. OWNERS TANK ID k j Bl MANUFACTURED BY: C. YEAR INSTALLED j Jp(j 0. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. E�J 1 MOTOR VEHICLE FUEL F-1 2 PETROLEUM B. I� CED 1 UNLEADED � 2 LEADED � 3 DIESEL 3 CHEMICAL PRODUCT 4 OIL PRODUCT ❑ 4 GASAHOL 5 JET FUEL ❑6 AVIATION GAS El 5 HAZARDOUS i� 80 EMPTY [:] 95 UNKNOWN 2 W STE E 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE:FUEL,ENTER NAME OF li HAZARDOUS SUBSTANCE STORED&C.A.S.# G.A.S.#:. n I III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A.TYPE OF ❑ 1 UOUBLE WALLED F_� 3 SINGLE WALLED WITH EXTERIOR LINER i� El 95 UNKNOWN SYSTEM Efl 2 SINGLE WALLED 4 SECCNDARY CONTAINMENT iY [::]'99 OTHER �TEELIIRON 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD WIFIBERGLASS REINFoxED PLASTIC , B.TANK [_� 5 CONCRETE 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM F 8 1004%METHANOLCOMPATIBLE FRP MATERIAL ❑ 9 BRONZE 10 GALVANIZED STEEL [:)95 UNKNOWN 99 OTHER F-] 1 Rl1BBER LINED El 2 ALKYD LINING 0 3 EPDXY LINING F-14 PHENOLIC LINING C. INTERIOR IN NG R F-] 5 GNSSLINING 6 UNLINED 1 95 UNKNOWN IS U k ING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT 3 VINYL WRAPEj 4 FIBERGLASSREINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ffl91 NONE 95 UNKNOWN 0'99 OTHER it h 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 (q,>5 UNKNOWN A U 99 OTHER B.CONSTRUCTION A Q1 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 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE{PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A]U 5 ALUMINUM A U 6 CONCRETE A U .7 STEEL CLAD W1 FRP A U 8 100%METHANOL COMPATIBLE FRP A jp U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER i h . V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. I IP S 1 VISUAL CHECK it P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 5 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISIONTFSTING' P S 7 PRESSURE TESTING P S 91 NONEs� P 5 95 UNKNOWN P S 99 OTHER VI. INFORMATION OP TANK PERMANENTLY CLOSED IN PLACE 4 1. ESTIMATED DATE LAST USED(MO/YRJ 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH t ll` SUBSTANCE REMAIN ING'IN GALLONS NERT MATERIAL? El YES NO 4 THIS FORM HAS SEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE-BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. , APPLICANT'S NAME(PRINTED 8 SIGNATURE) u DATE LOCAL AGENCY USE ONLY COUNTY# !r URISDICTION# AGENCY# �� FACILITY ID# TANK ID# H Fil 1 U n oCJ CURRENT LOCAL AGENCY( /0//?FACILITY IDN APPROVED BY NAME- PHONE N WITH AREA CODE 50 J FA -:34 IN !� � � ? �� PERMIT NUMBER I� PERMIT APPROVAL DATE PERMIT EXP4RATION DATE I I� IF I CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: 11I I -L- ..j t FORM B(13-29-88) THIS FORM MUST BE ACCOMPANIED -.A FACILITYISITE APPLICATION, FORM `A',UNLESS A C ENT FORMA' HA5 BEEN FILED ''I ..:. Z LOCALAGENCY OPY