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Fr STATE OF CALIFORNUWATER RESOURCES CONTROL1§OARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z 10 MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDEDPERMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED CAN q FACILITY/SITE NAME WHERE TANK IS INSTALLED: ,3 q S / FARM TANK-YE!X NO N F-� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY Ia A. OWNERS TANK ID# B. MANUFACTURED BY: u k C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: U�G II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM 0. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT ❑4 OIL ❑ 1 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&C.A.S.N C.A.S.#: EC III. TANK CONSTRUCTION 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 STEELIIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANKF-1 5 ❑6 POLYVINYLCHLORIDE 7 UM F-18100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ ❑10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER C.INTERIOR F7t RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 P ICUNING LINING ❑5 GLASS UNING F-16 UNLINED 5 UNKNOWN ❑ ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VI ❑4 RBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A FABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U / SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 9/ NONE 95 UNKNOWN U 99 OTHER B.CONSMUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE U 95 UNK WN U 99 OTHER A U 1 STEELPRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A UA U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP L U 95 A U 9 GALVANIZED STEEUN 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 tVISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 6 3VADOSE WELLS P�- %ITOR P S 5 GROUND WATER MONITORING WELLS P 5 5 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 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. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID R TANK ID# L: 10101oll CURRENT LOLL AGENCYfACILITJ(I�� APPROVED BY NAME PHONE p WITH AREA CODE PERMIT NUMBER (n, !`T1`i`7)/II��Il PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: \N1// 1 FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIEMY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CGHRENT FORMA HAS BEEN FILED DATA. PROCESSING COE'Y