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STATE OF CALIFORNIO WATER RESOURCES CONTROL 7ARD FORM 'B': UNDEWGROUND STORAGE TANK PRO�;FIAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE Z MARK ONLY A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _-❑y ❑ ❑ ❑ 10 IL.�VJA EW PERMIT 3RENEWAL PERMIT SCHANGE OF INFORMATION 7 RMANENTIY CLOSED K ONE ITEM 2INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED�Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: 303 S F ARM TANK-YES❑ NO ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY W W A. OWNERSTANK IDa B. MANUFACTURED BY: 1 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 17,6 oa II. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. 1 MOTOR VEHICLE L] I A F-13 CHEMICAL PRODUCTL [:] B 4 OIL ROLEUM /IPRODUCT 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 HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONST CTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A. TYPE OF I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 0 ❑ 1 STEEUIRON ❑ 2 STAINLESS STEEL ❑3 F18ERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. MATERIAL TANK ❑5 CONCRETE ❑ 6 POLYMNYLCHLORDE F-17 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL [:]95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD UNING ❑3 EPDXY LINING 4 OLIC UNING LINING ❑5 GLASSUNING ❑8 UNLINED 95 KNOWN M ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES E] NO 990THER VIIK D.CORROSION F-11 POLYETHLENE WRAP ❑2TAR OR ASPHALT ❑ 3 V RAP ❑/FIBERGLASS REINFORCED PLASRC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE TK 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 a2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED ALP 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 A U 6 CONCRETE A U 7 STEELCLADW/FRP A B 100`K 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 SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VAMSE WELLS 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 6 PRECISION TESTING P 8 7 PRESSURETESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER �i VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DA TE 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# = = = lolnl 1= laloioE CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE 14 PERMIT NUMBER PERMIT APPROVAL DATE / PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT s._I SURCHARGE XMT. FEE CODE PECEIPT# BY. FORM B(6-29-aa) THIS FORM MUST BE ACCO MPANI BY A FACILITY/SITE APPLICATION, FORM `7,UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY