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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION I--COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY u I NEW PERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7,PEflMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: - ST FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY •O A. OWNERS TANK IDR B. MANUFACTURED BY:C. YEAR INSTALLED �. D. TANK CAPACITY IN GALLONS: M111-111 II. TANK CONTENTS I (Ai),, MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. CJ1 A. ❑ I MOTOR VEHICLE FUEL PETROLEUM 8. FE-]-: 1EADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT 4 OIL ❑ ODUCT ❑4SAHOL ❑ 5 JET EL ❑6 AVIATION GAS 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN 2WATE ❑ 7 METHANOL OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED A C.A.S.R yd CAS.R: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,A D A TYPE OF ❑ WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM Z WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER .TANK 1 STEEURDN ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCEDPLASTIC B MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYO LINING ❑3 EPDXY LINING ❑4 HENOLJC LINING LINING El5 GLASS LINING [-]6 UNLINED N'OWN ❑ IS LINING MATERIAL COMPATIBLE WITH TIN METHANOL? ❑YES ❑ NO OTHER D. CORROSION ❑ 1 POLYETIILENE WRAP ❑2 TAR OR ASPHALT 3 VI ❑4 FIBERGLASS REINFORCED PLASTIC PflOTECTION 5 CATHODIC PROTECTION ❑ 91 NONE 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 U 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 U 2 DOU81-E 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 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U B 10096 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 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 6 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIALS []YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE 4 LOCAL AGENCY USE ONLY COUNTY 8 JURISDICTION N AGENCY R FACILITY ID N TANK ID R �] CURRENT LOCAL AGENCY FACILITY ID APPROVED BY NAME PHONE 1 WITH AREA CODE PERMIT NUMBER V PERMITAPPROVALDATE PERMIT EXPIRATION DATE "ZZ -10 CHECK R PERYR AYOUNT SURCHARGE ANT. FEE CODE RECEIPT 8 BY: 1� FORM B(6-29-86) THIS FORM MUST BE ACCOMPANI'ft'dY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY