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STATE OF CALIFORN WATER RESOURCES CONTR OARD °F FORM `B': UND GROUND STORAGE TANK PR RAM TANK TANK PERMIT APPLICATION INFORMATION " COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ' MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION El PERMANENTLY CLOSED TANK ONE ITEM 1:12 INTERIM PERMIT ❑ 4 AMENDED PERMIT [:]6 TEMPORARY TANK CLOSURE TANK REMOVED '991, FACILITY/SITE NAME WHERE TANK IS INSTALLED: /J r —FtFARM TANK - YES ❑ NO , I. TANK DESCRIPTION COMPLETE ALL ITEMS- IF UNKNOWN — SO SP CIFY f 1 0 A. OWNERS TANK ID # 41-- B. MANUFACTURED BY: F-13 CHEMICAL PRODUCT F-]4 OIL C. YEAR INSTALLED ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS D. TANK CAPACITY IN GALLONS: 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. #: 2 STAINLESS STEEL 3 FIBERGLASS 11. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. A 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED 4 3 DIESEL F-13 CHEMICAL PRODUCT F-]4 OIL 1 PRODUCT ❑ 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) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED & C.A.S. # C.A.S. #: 2 STAINLESS STEEL x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D A TYPE OF ❑ 1 DO LE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT 99 OTHER 3 GRAVITY A U STEEL/IRON 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENO LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED A UNKNOWN A ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT 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 TYPE A(6`7 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 5 UNKNOWN A U '99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP 4c -,%U A U 9 GALVANIZED STEEL A !U A5 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 1 VISUAL CHECKP S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 1P PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER li On INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST U ED (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH TANK ID # SUBSTANCE REMAINING IN INERT MATERIAL? ❑ YES ❑ NO 1 GALLONS 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 AGENCY USE ONLY COUNTY # JURISDICTION # AGENCY # FACILITY ID # TANK ID # P77 1 1 1 J E I () 10 1 t [ ol o I o:El CURRENT LOCAL AGENCY FACILITY ID # I APPROVED BY Nj%ME _ PHONE # WITH AREA CODE PERMIT NUMBER CHECK # PERMIT AMOUNT FORM B (3-7-88) THIS FORM MUST BE ACI PERMIT APPROVAL DATE PE / SURCHARGE AM FEE CODE FACILITY/SITEAPPLICATION, FORM `A', DATA PROCESSING COPY DATE RECEIPT # I BY: NT FORM `A' HAS BEEN FILED