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SPATE OF CALIFORN WATER RESOURCES CONTROARD ••':•ol ••. FORM B': UNDERGROUND STORAGE TANK PROGRAM C/ TANK PERMIT APPLICATION INFORMATION ' ~� TANK z COMPLETE A SEPARATE FORM WITH THE FOLLOW NG FORMATION FOR EACH TANK. 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ONE ITEM E]2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED 09 FACILITY/SITE NAME WHERE TANK IS INSTALLED: /61�� - FARM TANK-YES NO ❑ 1V 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECI J E53 7,!/ to A. OWNERS TANK ID# 11S. MAN UFACTURED BY: tlVl C. YEAR INSTALLED 0. TANK CAPACITY IN GALLONS: Q 11. TANK 22NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),ISH T MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM ilf-PZ C1 UNLEADED 2 LEADED DIESEL 3 CHEMICAL PRODUCT 4 OILROOUC ❑ 4 GASAHOL E] 5 JET FUEL ❑6 AVIATION GAS 5 HAZARDOUS BO 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.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.&D A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER 1 STEELJIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS F__j 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM 6 100%METHANOL COMPATIBLE FRP MATERIAL.. ❑ 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOUCUNING LINING ❑5 GLASS LINING 6 UNLINED 95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 10D%METHANOL? ❑YES ❑ NC ❑ 99 OTHER D.CORROSION ❑ 1,POLYETHI.ENEWRAP 2 TAR OR ASPHALT 3 VINYLWRAP E]4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN 99 OTHER 1V. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGRO ND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GF AViTY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOU8L.E WALLED A U 3 Ut ED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEELPRON A U 2 STAINLESS STEEL A U 3 K LYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.)MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 EL CLAD W/FRP A U 8 1 DO%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. P8 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 P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING INGALLONS INERT MATERIAL? [::]YES ❑4JQ :l THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY F JURISDICTION# AGENCY# FACILITY ID# TANKID# AGENCY CILITY ID at APPROVED Of NAME PRONE#WITH AREA CODE o m PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK/ PERMIT AMOUNT SURCHARGE AMT. FEE ODE CEIPT# BY: / or CNi� r FORM a(6-29-8e) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FO M 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED