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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD �;.: '•. FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION ' �o CO LETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. __ - Z 10 MARK ONLY NEW PERMIT ❑ 3 RENEWAL PERMIT HANGS OF INFORMATION ❑ 7 PERMANENTLYC ONE ITEM 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED O FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARMTANK-YES[ NO CAU I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY -4 A. OWNERS TANK ID# /pk: r/L# ✓3 B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS D It. TANK CONTENTS IF(A.1) S MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. TOR VEHICLE FUEL 2 PETROLEUMB. C. ❑ 1 UNLEADED ❑ 2 LEADED DIESELdk;.J_ F-13 CHEMICAL PRODUCT F-14 OIL 1 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 ) G.A.ZARDOUS SUBSTANCE STORED&C.A.S.# �/ A.S #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OFI DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑ 2 SWOLEWALIED - 4 SECONDARY CONTAINMENT ❑99 OTHER STEEL/IRON _ ❑2 STAINLESS STEEL F] 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS flENFORDED PLASTIC S. MATERIAL ❑5 CONCRETE E]6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑8100%MEMANOL COMPATIBLE FRP [:]9 BRONZE',, , ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN [:] ISUNINGMATERULOOMPATIBLEWRHIW%METHANOL? ❑YES ❑NO [ja<OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODICPROTECTION ❑ 91 Nop' .-E]95 UNKNOWN OTHER ✓L IV. PIPING INFORMATION CIRCLE A IFABOVE GiOUN , U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U i SUCTION A Ur 2 RRES$URf A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FISERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A�"U��.��6�CONCRETE A U 7 STEEL CLAD W/FRP A U S TBD%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A lIt UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR q f'OR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. ( P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WEL P 4 ELECTRONIC MONITOR- P 5 O GROUND WATER MONITORING WELLS 2� P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P B 95 UNKNOWN P S 99 OTHER W L-BVI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(M / R) 2. ESTIMATED QUANTITY OFGALLONS 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? YES ❑ NO THIS FORM HAS BEE COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE 1 LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# In CURRENT LOCAL AGENCY FACILITY ID• APPROVED BY%NA PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE RMIfFXPIRATIOW DATE C CHECK PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: V FORM B(6 29 88) THIS FORM MUST BE ACCOMPANIE!wdV A FACILITY/SITE APPLICATION, FORM 'A',UNLESS AVARENT FORMA' HAS BEEN FILED DATA PROCESSING COPY