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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ Z i O MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 P RMANENTLYCLO TAN ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED D CJ.7 FACILITY/SITE NAME WHERE TANK IS INSTALLED: Vim" FARM TANK-YES❑ NO N T`J I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY (j( A. OWNERS TANK ID#D B. MANUFACTURED BY: C. YEAR INSTALLED U D. TANK CAPACITY IN GALLONS: dO O II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. CLE A ❑3 C EMICALPIRODUCTL ❑ 4 OILROLEUM B 1 PRODUCT C ❑4 GASAHOLD ❑ 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 A-/ /A / HAZARDOUS SUBSTANCE STORED&CAS.# A.v R C.A.S.#: A-//A 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BORA B,C,&D A.TYPE OF DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑ 2 STAINLESS STEEL [--1 3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC 8.TANK MATERIAL F-15 CONCRETE E]6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑810091 METHANOL COMPATIBLE FRP [:j 9 BRONZE ❑ 10 GALVANI2®STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER LINED ❑ 2 DLINING ❑3 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑5 GLASS LINING 6 UNLINED ❑95 UNKNOWN E] IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? E]YES ❑ NO rN OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP TAR OR ASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMAT ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE 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 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH 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 SALUMINUM A U 6CONCRETE A U 7STEEL CLAD W/FRP A U 81 DO%METHANOL COMPATIBLE FRP A 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. P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS /VI"NC P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 9/ NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE EAST USED(MCiYR) 2. ESTI TED QUANTITY OF 3.WAS TA K FILLED WITH ^ SU ACE REMAINING IN IN RT RIAL? ❑YES [—]NO J+ GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENAL 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# JURISDICTION# AGENCY# FACILITY ID# TANK ID# I k I 7 o CURRENT LOCAL AGENCY FACILITY IDX APPROVED BY NAME PHONE N WITH AREA CODE u PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE HECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: XWe FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIEV WY A FAZB.ITY/SITE APPLICATION, FORM 'A',UNLESS ALOpRENT"FORM W HAS BEEN FILED