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STATE OF CALIFORNIO WATER RESOURCES CONTROI ')ARD - FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ MARK ONLY 1 NEWPERMIT ❑3 RENEWALPERMIT 215 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK EC ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMITC '❑16 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED ' 5 1 FACILITY/SITE NAME WHERE TANK IS INSTALLED: 2 AjE4 D ,EMFARM TANK-YES❑ NO � N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY d A. OWNERS TANK IDR (D B. MANUFACTURED BY: V C. YEARINSTALLED R e D. TANK CAPACITY IN GALLONS: p DDD II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL F-12 PETROLEUM B. C. ❑ 1 UNLEADED [:]2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT [:]4 OIL 2-1PRODUCT ❑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.R C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ 1,gNBLEWAUfD ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SEOONDARYOONTAINMENT ❑W OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 RBERGUSS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PUSTIC B. TANK ❑ MATERIAL 5 CONCRETE ❑6 POLYVINYLCHLORIOE ❑ 7 ALUMINUM ❑B 100%METHANOLCOMPATIBLEFRP ❑9 BRONZE ❑10 GALVMIZEDMEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RIBBER LINED ❑2 ALKYD LINING 'SEPDXY UNING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED / ❑95 UNKNOWN [-]IS LINING MATERIAL COMPATIBLE WITH 1011%METHANOL? YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 PMYETHLENE WRAP ❑2 TARORASPHALT ❑3 N WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALLED A U 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 STEELCLAD W/FRP A U 8 100%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 8 1 VISUAL CHECK 6G 8 2 INVENTORY RECONGLIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P�6 PRECISION TESTING P 8 7 PRESSURETESTING P 8 91 NONE P B 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY R FACILITY ID R TANK ID# ® 10101D G( o C) CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE - PERMIT NUMBER PERMIT APPROVAL DATE PERMITEXPIRATION DATE 1y^1 CHECKM PERMIT AMOUNT SURCHARGEAAIT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM'A',UNLESS A CURRENT FORMA HAS BEEN FILED 1 DATA PROCESSING COPY