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STATE OF CALIFORNIA WATER RESOURCESCONTRO' 'O`D FORM `B': UNDERGFMUND STORAGE TANK PROMAIM mom. TANK TANK PERMIT APPLICATION INFORMATION m, COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 7] 1 NEWPERMIT F-13 RENEWALPERMIT [e'5CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLANOFq-' ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: , L ' e- FARM TANK-YES❑ q I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY ILO A. OWNERS TANK ID# B. MANUFACTURED BY: LLQ C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 1.P II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A7),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C UNLEADED ❑ 2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT 4 OIL EE'l 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 8 C.A.S.N NA C.A.S.H: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.A D A TYPE OF ❑ I DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR UNER 95 UNKNOWN SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEUIRON 2 STAINLESS STEEL F-1 3 FIBERGLASS F-1 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK 5 CONCRETE 6 POLYVINYLCHLORIDE n 7 ALUMINUM ❑B 1OD%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE ID GALVANIZED STEEL 95 UNKNOWN Ej N OTHER 1 RUBBERUNED 2 ALKYD LINING 3 EPDXY LINING F-14 PRENOUGUNING C. INTERIOR LINING ❑5 GLASS LINING El 6 UNLINED Fg�UNKNOWNI ❑ IS LINING MATERIAL COMPATIBLE WITH IDD%METHANOL? ❑YES ❑ NO 99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP 0 2 TAA OR ASPHALT 3 VINYL WRAP 4 F18MLAM REINFORCED PLASTIC PROTECTION Ej 5 CATHODICPROTECTION91 NONE ❑95 UNKNOWN 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE IPVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 1 OD%METHANOL COMPATIBLE FRP A U 9 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 5 1 VISUAL CHECK 05 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 6 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE- P B 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH A SUBSTANCE REMAINING IN INERT MATERIAL? YES ❑NO 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY N FACILITY ID M TANK ID M 3 � = lololilo-FoTT -1061oll CURRENT LOCAL AGENCY FACILIj ID#-75 APPROVED BYYNAMFy_ PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE Oa PERMIT EXPIRATION DATE CHECKX PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: v FORM B(3-7-BB) THIS FORM MUST BE ACCOMPANIEft?A FACILITY/SITE APPLICAT1011, FORM`A',UNLESS A'�MRENT FORMA' HAS BEEN FILED TTA PROCESSING COPY _