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STATE 0PCALIFORN1L WATER RESOURCESCONTRL. , 80ARD FORM 'B' 'UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION t.''•(: COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z MApK ONLY �,-'❑ I NEW PERMIT. ❑3 RENEWAL PERMIT �5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED _ I O ONE ITEM I-(;. ❑ 2 INTERIM PERMIT ❑ 1 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED W FACILITY/SITE NAME WHERE TANK IS INSTALLED: >> F V - J(riST FARM TANK•YES❑ NO fV O L TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY (D A OWNERS TANK ID 1 W q 11 B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: /VQG 6 II. TANK CONTENTS IF(A.1),19 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 ROLEUM B, C. ❑ I UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT 1 OIL �pp00(JCT ❑1 GASAHOL ❑ 5 JET FUEL ❑ fi AVIATION GAS ❑ 5 HAZARDOUS ❑ SO EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW( D. IF ANOT MOTOR VEHICLE FUEL,ENTER NAME ZARDOUS SUBSTANCE STORED 3 CS.NOF AL zrre t. c) , CASA: L/ D III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXA,B,C,LD A.TYPE OF ' . ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EATEAIOR LINER ❑ 95 UNKNOWN SYSTEM ' ❑2 SINGUIVALLED ❑ /SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIROI ❑2 STAINLESSSTEEL ❑ 3 FIBERGLASS ❑ 1 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC 8.TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVIWLOLOPoOE ❑ 7 ALUMINUM ❑ 6 tOAMSMNOL COMPATIBLE FRP ❑ 9 BRONZE Q 16 GALVMIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C INTERIOR : ❑ 1 RUBBERUNED ❑ 2 ALKYD LINING ❑ 3 UOXYUNING ❑ 1 PHENOUCUNING . LINING, ❑ S.GLASS LINING ❑ 6 UNLINED ❑ 95 UWWOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IOD%MEl%UIOL2 ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETNE WRQ ❑ 2 TMONASPHAET ❑ 3 VINYL WRAP ❑/RBERGUSSNEWFORCEDPUSIIC 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 I 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 I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEUIRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U I FIBERGLASS PIPE A U 91 NONE D.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B I009L METHANOL COMPATIBLE FRP A U 9 OALVANIZEO STEEL A V 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. LP t 1 VISUALCHECK P 6 2 INVENTORY RECONCILIATION P t 3 VADOSE WELLS P t 1 ELECTRONIC MONITOR P t 5 GROUND WATER MONITORING WELLS P t s PRECISION TESTING P t 7 PRESSURE TESTING P t 91 NONE P t 95 UNKNOWN P t 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED IMO/YR) 2. ESTIMATEO OUANTITY OF 3. WAS TANK FlLLED 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 tFFI NTEO S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY I JURISDICTION f AGENCY I FACILITY ID I TANK ID I CURRENT LOCALAGENCY FACIUTY 106 APPROVED BY NAME PHONE/WITH AREA CODE PERMITNUUBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKI PEN MITAMOUHT 7 SURCHARUE AMT. FEE CODE ECEIPTI BY: / G � ,• FORM a(6-29.51) THIS FORM MUST BE ACCOMPANIED BYAFACILITY/SITE APPLICATION. FORMA' TIMIP[<LruPncuT ��..