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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD =_ FORM 'B': UNDERGROUND STORAGE TANK PROGRAM j TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ;tl MARK ONLY 1L5 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED T K ONE ITEMINTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: O FleC fRoIVFARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY i0 A. OWNERS TANK IDN 'f i B. MANUFACTURED BY: C. YEAR INSTALLED 5 IV I D. TANK CAPACITY IN GALLONS: s II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. / � OD LUNLEADED A. � MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. 1 PRODUCT C 1 GASAHOL ❑5 JET FUEL ❑ 3 AG TION GAS ❑3 CHEMICAL PRODUCT ❑ 4 OIL ❑ ❑ ❑ ❑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 C.A.S. F� HAZARDOUS SUBSTANCE STORED&C .S.# CAS.W MI. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C.&D A TYPE OF -] 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN U SYSTEM P/2SNGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MMATERIALF-15 CONCRETE 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOLCOMPATIBLEFRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC UNING V LINING ❑5 GLASSUNING ❑6 UNLINED 5 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 1OD%MEMANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP Fa TARORASPHALT ❑3'AWL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER i IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A .0 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLWINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C.MATERNA- A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AG 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 P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING P S 7 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 P6 1 GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? E]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# TANK ID# 1 1010101-11 L GENCY FACILITY 10 pPPRO D N E PHONE#WITH AREA CODE C71-2 Olw� PERMITA pOVWZIL DA PERMIT EXPIRATION DATE PERMIT AMOUNT SURCHAR6EAMfT. FEECODE RECEIPT# BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANII:Irwe A FACILITY/SITE APPLICATION, FORM 'A',UNLESSv...OARENT FORMA HAS BEEN FILED , A P,Tocess -