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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION j COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ - z MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATIONII❑ 7 PERMANENTLY CLOSED TANK I C? ONE ITEM F-12 INTERIM PERMIT F-] ��4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE Y�TANK REMOVED N FACILITY/SITE NAME WHERE TANK IS INSTALLED: I(Sn I ) N FARMTANK-YES❑ NO j! I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY C) _ O A. OWNERS TANK ID# Ono B. MANUFACTURED BY: U�; W C. YEAR INSTALLED _ 4'ry'7 L D. TANK CAPACITY IN GALLONS. II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. &I MOTOR VEHICLE FUEL 2 PETROLEUM B FE 1 PRODUCT C ❑1 GASAUNLEHOL ❑5 JET FUEL ❑6 AVIATION GAS ED 3 DIESEL 3 CHEMICAL PRODUCT 4 OIL 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN2 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.If C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I DOUBLE WALLED ❑ 33114GLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM Ei?2 SINGLE WAILED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER C 1 STEBUIRON ❑2 STAINLESS STEEL ❑3 RBERGLASS ❑4 BTEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑ MATERIAL 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑610A METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER UNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING E1,6 UNLINED ❑9�5 UNKNOWN THA ❑ IS LINING MATERIAL COMPATIBLE WITH IOD%MENOL? ❑YES F] 1�C NO [� OTHER L D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR ON ASPHALT ❑3 VINYL 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 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 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE 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 S ALUMINUM A y 6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 5 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 1 VISUALCHECK O8 2 INVENTORY RECONCILIATION P 8 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 ] PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 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 17 COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# m Dd / S I -61FI Id0 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE C 1117 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE \`1 CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT k BY: ) \\JI FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIEDvY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM W HAS BEEN FILED