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STATE OF CALIFORNIA - WATER RESOURCES CONTROL )ARD ;. FORM 'B': UNDERGROUND STORAGE TANK PROGRAM ` TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. "z. 0 10 MARK ONLY ❑ 1 EW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO TANK ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 2 FACILITY/SITE NAME WHERE TANK IS INSTALLED: E L FARM TANK-YES NO (A) I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N 9� A. OWNERS TANK IDN 0 7 B. MANUFACTURED BY: C.YEAR INSTALLED 3 D. TANK CAPACITY IN GALLONS: /01 b0c) II. TANK PONTENTS IF(A.%IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUMC. ❑ 1 UNLEADED ❑2 LEADED DIESEL B. ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 6<PRODUCT ❑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 A C.A.S.# `N/ C.A.S.#:AJIA 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,AD 1 BLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN A TYPE OF ❑ SYSTEM Ln 2 SI GLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CUD W/RBERGLASS REINFORCED PLASTIC S.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑8 1D)%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 LINING F13 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS UNING 6 UNLINED ❑95 OWN'-�(� ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 990TBER ��✓✓✓� D. CORROSION ❑ 1 POLYETHLENE WRAPf 1 2 TAR DR ASPHALT ❑ 3 VINYLWRAP ❑ 4 RBEGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORM ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE 4 4 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A Wl SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNEDTRENCH 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 5ALUMINUM A�6 CONCRETE A U 7STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A 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 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURETESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE USED(MO/YR) 2. ESTIMATED QUANTITY OF 1 3.WAS Tf I INKFILLED WITH // / NC SUBST INING IN GALLONS I E TERIAL? YES ❑NO THIS FORM FIAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWL DGE IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3 o I I 3 l 1010 lo 13 CURRENT LOCAL AGENCY FACILITY ID# APP D BY ME PHONE#WITH AREA CODE Pl ' v PER IT NUMBER PENIMT ArPROVAL /ADlA I PERMIT EXPIRATION DATE N Y— CHECK# PERMIT AMOUNT I SURCHAIIQEA . FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLE'SASORRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY