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STATE OF CALIFORNit WATER RESOURCES CONTROI ')ARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. -- MARK ONLY ❑ ❑ ❑ ❑ 1 Cl 1NEW PERMIT 3RENEWAL PERMIT SCHANGE OF INFORMATION 7P MANEN7LY CLOSEDTA ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE EBB TANK REMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3-535 E, FARM TANK-YES❑ NO ❑ CD I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY � A. OWNERS TANK IDR B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Q 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A ❑ 3 MOTORCHEMiVEHICLE FUEL ❑2 OIL ROLEUM B pRODUC7 C ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑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.R / �� C.A.S.M 494? 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A. TYPE OF ❑ I DOUBIEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 51EEL11flON STAINLESSSTEEL ❑3 FIBERGLASS ❑45TEEL CLAD W/FlBERGUSS REINFORCED PLASRC B.TANK ❑ 5 CONCRETE ❑6 LYV CHLORIDE ❑7 ALUMINUM ❑81DA METHANOL COMPATIBLE FAP MATERIAL ❑ 9 BRONZE 10 VANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNEO 2 ALM TNG ❑3 EPDXY UNING 4 PHEROUC LINING C.INTERIOR LINING ❑5 GUSSUNING ❑6 UNUNED 95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%M L9 ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP 2 TAR OR ASPHALTF-13 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASAC PROTECTION [—]5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, 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 1 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 STEEL/IRON A U 2STAINLESS 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 U 7 STEELCLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR kcONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION ■ 8 3 VADOSE WELLSP 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLA 1.ESTIMATED DATE LAST USED(MOLAR) 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(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY N FACILITY IDR TANK ID R ® I (101110oa aoof CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY NAME PHONE N WITH AREA CODE 3s s 9 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE \) CHECKN PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: W/ FORMB(6-29-68) THIS FORM MUST BE ACCOMPANIED FAMMISREAPPLICATION, FORM'A!,UNLESS A CDRRENT FORMA' HASBEENFILED DATA PROCESSING COPY