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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 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 NEW PERMIT ❑ 3 RENEWALPERMIT &I CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 07 L /� FARM TANK-YE8❑ .NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 A. OWNERS TANK IDH :3(-) -7- S. MANUFACTURED BY: C. YEAR INSTALLED / D. TANK CAPACITY IN GALLONS: W 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. w CA A. 191 l MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. �rUNLEADED ❑ 2 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT ❑4 OIL ®'rPROOUCT ❑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.X: .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.a D A TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM [5j?SINGLE WALLED ❑4 SECONMRY CONTAINMENT ❑99 OTHER QT-IBTEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLA91C B.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED MR ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ i RUBBER UN® ❑2 ALKYD LINING F-13 EPDXY LINING ❑4 PHENOLIC LINING T�7,� J" LINING ❑5 GLASS LINING ❑6 UNLINED UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOP ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAA OR ASPHALT ❑�I!3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION [—] 2i 5 CATHODIC PROTECTION ❑91 NONE S UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 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 eV95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C, MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U S 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A O45 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 S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS Q S fi PRECISION TESTING P 8 7 PRESSURETESTING P 8 91 NONE P 8 95 UNKNOWN P S 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 M1'KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION N AGENCY# FACILITY ID 8 TANK ID N �] d o Oo0 CURRENT LOCAL AGENCY M7 ITY IDN APPROVED BY NAME PHONE!WITH AREA CODE 2 PERMITN MBER PERMIT APPROVAL DATE PERMIT EXP O DA CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(3-7-fie) THIS FORM MUST BE ACCO MPAaIEO BY A FACILITYISITE APPLICATION, FORM'A',UNLE ARM FORMA' HAS BEEN FILED C- DATA PROCESSING COPY J