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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION m ; COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ;d MARK ONLY 1 NEW PERMIT F-13 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM INTERIM PERMIT ❑4 AMENDED PERMIT ❑Q6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 6 FACILITY/SITE NAME WHERE TANK IS INSTALLED: �,Q� , F/` En?O FARMTANK-YES❑ NO ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TA NK IDA C�, B. MANUFACTURED BY: C. YEAR INSTALLED s D. TANK CAPACITY IN GALLONS S. / W 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 ❑ 2 PETROLEUM B. / C. ❑ 1 UNLEADED2 LEADED ❑3 OIESfEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL a PRODUCT ❑4 GASAHOL ❑ 5 JE7 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 8 C.A.S.II C.A.S.R: .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a o A. TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ED-E'SINGIE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 5MUIRON ❑2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STE OADW/FIBERGLASSREINFORCED PLASTIC B.TANK MATERIAL F-] 5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVAMZE D MEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER LINED ❑2 ALKYD LINING F-13 EPDXY LINING ❑4 PHENOUC UNING LINING ❑5 GUSS LINING ❑8 UNLINED ❑ 95 UNKNOWN ❑IS LINING MATUHALCDMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑%OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TM OR ASPHALT ❑ 3 VINYL 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 A U 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 U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLOROE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 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 S I VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURETESTING P 8 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 COUNTY A JURISDICTION A AGENCY A FACILITY ID If TANK IO S 4 � s7 / OD lo Pq CURRENT LOCAL AGENCY FACILITY p NS APPR VE 8Y AME PHONE N WITH AREA CODE PERMITNUMBER C (7L PERMIT APPNO� TE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT j_SURCHARf3E A T. FEE CODE RECEIPT A BY: vV`v1 / FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIb4IrYA FACILITY/SITE APPLICATION, FORM 'A',UNLE RRENT FORMA' HAS BEEN FILED TATA PROCESSING COPY