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STATE OF CALIFORNI#b WATER RESOURCESCONTROSARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM " TANK TANK PERMIT APPLICATION INFORMATION m,l� COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 10 MARK ONLY ❑ 1 N PERMIT F-] 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 11 w , � ) FACILITY/SITE NAME WHERE TANK IS INSTALLED: �/v FARM TANK-YES❑ NOEfr N W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 0 A. OWNERS TANK ID# O B. MANUFACTURED BY: _ C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 14000 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,1 COMPLETE ITEM A. 1 MOTORVEHICLE FUEL F-12 PETROLEUM C. ❑ UNLEADED 2 LEADED ❑ 3 DIESEL B. ❑3 CHEMICAL PRODUCT ❑ 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.#:A A4 Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D 1 UBLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER A TYPE OF ❑ ❑ 95 UNKNOWN SYSTEM 2 SI LE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON 2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE [:] 10 GALVANIZED STEEL E]95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR 1 RUBBERLINED LKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC UNING LINING F-]5 GLASS LINING6 UNLINED 95 UNKNOWN`, ❑ IS LINING MATERIAL COMPATIBLE WRH METHANOL? ❑YES ❑ NO [:J�THER D.CORROSION ❑ 1 POLYETHLENEWRAP 21 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION E] 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 112, SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A(y 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 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM ACONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 5 UNKNOWN A U 99 OTHER V EAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS S 6 PRECISION TESTING S T PRESSURE TE STING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMA E DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY F 3.WAST K FILLED WITH SUBSTANCE REM NI GALLONS IN IN AT IAL?. YES [:j NO IA I In THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJUR ,AND TO THE BEST OF MY KNOWLE GE;IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# Ed 3 00 1 2 CURB NT LOC AGENCY FACILITY ID# APPR VEED^/BY NAME PHONE#WITH AREA CODE 6C_/ 11) I PERMIT NUMBERMITA ROVAL PERMIT EXPIRATION DATE P DA al CHECK# PERMIT AMOUNT I SURCOOGIEA T. FEECODE pECEIPTIt BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANI u Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESgWRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY