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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'B': UNDERGROUND STORAGE TANK PROGRAM Qp <br /> TANK °' TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING I N <br /> HMATION FOR EACH TANK. <br /> MARK ONLY ❑ I NEW PERMIT ❑O RENEWALPERMIT5 CHANGE OF INFORMATION C-] 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM E]2 INTERIM PERMIT 6 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE [j 8 TANK REMOVED 0'7 <br /> FACILITY/SITE NAME WHERE TANK 18 INSTALLED: S `����� FARMTANK-YESO NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A OWNERS TANK 10/ --/ B. MANUFACTURED BY: <br /> C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: S/ LJ r• <br /> II. TANK CONTENTS IF(AL1),18 MARKED,COMPLETE ITEM C.IF(A.1).IS NOT MARKED,COMPLETE ITEM D. <br /> A n !/MOTOR VEHICLE NEL 2 PETROLEUMC. ❑ I UNLEADED 2 LEADED Lj 0 DIESEL <br /> LrnV I/O CHEMICAL PRODUCT 1 OIL - B. 1 PROOUCT ❑/ GASAHOL 5 JETFYEL r_� 8 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY ❑ 95 UNKNOWN 0 2 WASTE ❑ 7 METHANOL Q-50'OTHER(DESCRIBE IN ITEM D.BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF ,y <br /> HAZARDOUS SUBSTANCE STORED 6 CAS.1 /(/'LZ C/v 'L C.A.S.1: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN SOX A,B,C,f D <br /> A.TYPE OF ❑ I WALLED 0 SINGLE WALLED WITH EXTERIOR LINEA 95 UNKNOWN <br /> SYSTEM SIROLE WALLET) /SECONOVNCONTAINMEM 99 OTHER <br /> TANK 0 1 STEEUBION 2 STAINLESS STEEL ❑D FIBERGLASS 6 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> S.MATERIAL ❑5 CONOETF 6 POLMMOILOPoOE E] 7 ALUMINUM 8 I0D%METHANOL COMPATIBLE RIP <br /> 9 BRONZE E] 10 GALVANIZED STEEL [:].95 UNKNOWNOTHER i <br /> C.INTERIOR I RUBBEAUNED ❑.�2AMUNING F1 7 EPO%1'UWNG Ej 1 PHENOUCUNING <br /> LINING ❑ 5 GLASS LINING r�S2AIJNED 0 95 UNKNOWN <br /> BLNING MATERIAL COMPATIBLE WITH 100%METHANOL? EjYES EjNO 99 OTHER <br /> D.CORROSION ❑ 1 POLYEHRENEWRIP [:]2TAA M T 0 WNYLWPAP /FIBERGLASS REINFORCED PIATIC <br /> PROTECTION 5 CATHODIC PROTECTION - NONE 95 UNKNOWN 91 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND,BOTH IF APPLICABLE <br /> EA YPE A U SUCTION A U 2 PRESSURE A U O GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> EWALLED A U 2 DOUBLE WALLED A U O LINED TflENCH A U 97 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A 1 STEEL/IRON A U 2 STAINLESSSTEEL A U DI POLWINYLCHLORIDE(PVC) A U I FIBERGLASS PIPE A U 91 NONE <br /> A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 TDO%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZEDSTEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P ! I VISUALCHECK F / 2 INVENTORY RECONCILIATION P I D VADOSE WELLS P S A ELECTRONIC MONITOR P I S GROUND WATER MONITORING WELLS <br /> P 6. 6 PRECISION TESTING P 1 7 PRESSURE TESTING P f 91 NONE P 6 95 UNKNOWN P / 99 OTHER <br /> Vi. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> I. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF S WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN INERT GALLON! MATERIAL7 DYES [:] NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE ANO CORRECT. <br /> APPLICANT'S NAME(PRINTED A SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY 1 TJURISDICTION I AGENCY 1 FACILITY ID I T�AYNK ID 1 <br /> r/ ( © 6) 07 <br /> CURRENT LOCAL AGENCY FACILITY 10 1 APPROVED BY NAME PHONE I WITH AREA CODE <br /> PERMIT NUM09A PERMIT APPROVAL OAT% PERMIT EXPIRATION DATE <br /> CHEC KIT PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT <br /> Fnnu AIA.79.M1 TNIAFORMMIINTRFIrrnunl WSn PY/[Irum,etnlmirinnu Cn O II .Al um eww♦mmnwm w........• n............... <br />