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STATE OF CALIFORNIA WATER RESOURCES CONTROI 7 D (Y?llr(q'Oa- T FORM 'B': UNDEK-UROUND STORAGE TANK PROGkAM I m TANK TANK PERMIT APPLICATION INFORMATION C COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK IO MARK ONLY F-11 NEW PERMIT ❑ ❑3 RENEWAL PERMIT 5 C ❑ ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 6 TANK REMOVED o 0( FACILITY/SITE NAME WHERE TANK IS INSTALLED:303 S. ^1 FARM TANK-YES❑ NO ❑ N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 0ITL3&78 CD A. OWNERS TANK ID# B. MANUFACTURED BY: c C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 12 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. -] 1 UNLEADED 2 LEA [KI MOTOR CLE DED Mr3 DIESEL A ❑3 CHEMICAL PRODUCT CTL ❑ 4 OI�OLEUM PRODUCT C ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS -15 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.# C.A.S.#: 111. TANK CONSTR TION MARK ONE ITEM ONLY IN BOX A,B,C.8 D A.TYPE OF 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ i STEEL/IRON ❑2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE .❑6 POLYVINYLCHLORIDE 7 ALUMINUM B 10D%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER LINED ❑2 ALKYDUNING ❑3 EPDXY LINING ❑ (PHENOLIC LINING LINING F-15 GLASS LINING ❑6 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYEfHLENEWRAP ❑2TAR OR ASPHALT ❑3VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 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 A U 1 SUCTION A 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 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 @114FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 1017%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 8 1VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3VADOSE WELLS®1 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P S 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 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# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 0 CURRENT LOCAL AGENCY FACILITY ID 4 APPROVED BY NAME PHONE k WITH AREA CODE u � PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. ' FEE CODE RECEIPT BY: /S 9/ C FORM B I6-29-BBI THIS FORM MUST BE ACCOMPANIEu BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CU RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY