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STATE OF CALIFORN10 WATER RESOURCES CONTR*OARD FORM B': UNDERGROUND STORAGE TANK PROGRAM } � mo TANKTANK PERMIT APPLICATION INFORMATION NK. 71, COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TA MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CL K ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED N FACILITY/SITE NAME WHERE TANK IS INSTALLED: /gyp FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPEC FYCD � � A A. OWNERS TANK ID# B. MANUFACTURED BV'. S C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS'. II. TANK ONTENTS 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 DIESEL 3 CHEMICAL PRODUCT F-] 4 OIL 1 PRODUCT 4 GASAHOL Ej 5 JET FUEL 6 AVIATION GAS 5 HAZARDOUS 80 EMPTY [E::] 95 UNKNOWN 2 WASTE 7 METHANOL E] 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.N'. HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE Of Q I OUBLEWALLED F-] 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2 NGLE WALLED F-14 SECONDARY CONTAINMENT 99 OTHER Df 1 STEEL71RON F-1 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEELCLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE F-1 6 POLYVINYLCHLORIDE F-] 7 ALUMINUM 8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL E]95 UNKNOWN 99 OTHER 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING C. LINING INTERIOR F-15 GLASS LINING F-] 6 UNLINED E NKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? E]YES [:] NO 99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP F-1 2 TAR OR ASPHALT ❑ 3/ML WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION E]5 CATHODIC PROTECTION [:] 91 NONE %UNKNOWN 99 OTHER IV. PIPING INFORM ION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE ;t2 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 5 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 U 5 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 A U 91 NONE C.MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 5 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. S 1VISUALCHECK P S 21NVENTORY9ECONCILIATION P S 3VADOSEWELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER F1 r E 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 MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLYNTY# COU ��URISDICTmmON# AGENCY# FACILITY ID# TANK ID# L� � o 25 D 6 U 1 y2�� / APPROVED BY N I PHONE N WITH AREA CODE CURRENT LOCAL AGENCY FACILITY ID NI V-Vl/jNA PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK* PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT FORM 6(6-29-66) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA HAS BEEN FILED \ DATA PROCESSING COPY J