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STATE OF CALIFORNI, WATER RESOURCES CONTRC 'OARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK TANK. MARK ONLY ❑ I NEWPERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: Pir S T FARM TANK-YES❑ NO vr Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY i A. OWNERS TANK IDN B. MANUFACTURED BY: C. YEAR INSTALLED ��i. / ' D. TANK CAPACITY IN GALLONS' d II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. F+ A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS p. ❑ 5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN REM D,BELOW) 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# A119 C.A.S.#: ■ ll. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,!D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM /SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER F-1 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 MEL CLAD IN/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 1DD%METHANOLCOMPATISLEFRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL F 95 UNKNOWN ❑99 OTHER C.INMIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑5 GLASS LINING ❑8 UNLINED f�j4s UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE V UNKNOWN ❑99 OTHER I 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 IL CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A Ig>95 UNKNOWN A U 99 OTHER � A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(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 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A95 UNKNOWN A U 99 OTHER tip V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR IS FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. yyyy PAY P 8 1 VISUAL CHECK 10 S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS 41 J P 8 6 PRECISION TESTING P 8 7 PRESSURETESTING P S 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 414SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES NO GALLONS 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# JURISDICTION# AGENCY# FACILITY ID# TANK ID# ol 6 % / 1r" d 010 101 / 1 1 CURRENT LOCAL AGENCY FACILITY ID x APPROVED BY NAM PHONE#WITH AREA CODE N o �3 8a� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT LI IRCHARGE AMT. FEE CODE RF^EIPT# BY: FORM B(3-7 8 ) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA HAS BEEN FILED S ^ATA PPOCFSSING COPY