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STATE OF CALIFORNIt WATER RESOURCES CONTROI OARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _- z a cQ MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED T NK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMITTEMPORARY TANK CLOSURE ❑8 TANK REMOVED IV FACILITY/SITE NAME WHERE TANK IS INSTALLED: 2-36M FARM TANK-YES❑ 4116 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A A. OWNERS TANK ID# F."Jv I -O 4 1 B. MANUFACTURED BY: uL) -!74 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 2 c -D-D Enil I1. 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 UNLEADED ❑2 LEADED dE 3 ❑3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑ 6 ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN IT D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED A C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLYIN BOXA,B,C,BD A.TYPE OF ❑ 1 DOUBLE WAILED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM tat SINGLE WALLED ❑4 SECONDARYCONTAINMENT ❑99 OTHER ®1 STEEUIRON ❑2 STAINLESS STEEL ❑ 3 RBERGUSS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑81UD%METHANOL COMPATIBLEFRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑%OTHER C. INTERIOR F-11 RUBBER LINED 2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOUC UNING LINING ❑5 GLASS LINING 6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO - ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP jRr2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE ❑%UNKNOWN ❑%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 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED , A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A CO 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 5 ALUMINUM 6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A( UU 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. V/ P S 1 VISUAL CHECK Ip/8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 2 5 GROUND WATER MONITORING WELLS FJJ P 6>6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P S 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 GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES EJNO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. 1 APPLICANT'S NAME(PRINTED 851pNATURE) DATE LOCAL AGENCY USE ONLY �JJ I Illi y' COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 39 = = 1012 1003 CUkRENT LOCAL AGENCY FACILITY ID# APPROVED BY NA PHONE#WITH AREA CODE mw3 -9 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-BB) TRIS FORM YUBT BEACCOM BYAFACILITY/SITEAPPLICATION, FORM `A',U RRENT FORSUN HASBEENFILED DATA PROCESSING COPY